Transitional Care When You Need it Most
The TACT (Transition Across the Community Team) Program is a patient-centered program designed to improve quality of life, reduce re-hospitalization and contain costs for patients who are 18 years of age and older and are considered high risk. This program provides TACT Nurse/Care Manager to guide patients as they transition across multiple health care settings.

How It Works
During an episode of illness, you may receive care in multiple settings, often resulting in incomplete or confusing information. Since you and your family are most involved with your care, this program focuses on providing you and your family with information necessary to manage your own care, improve your quality of life, and know where to go for assistance within the health care system.

Following a referral, a TACT Nurse/Care Manager will provide you with specific written material, information and self-management skills to ensure that your needs will be met when you receive additional care in multiple settings in the future.

TACT is provided at no cost to you.
For more information, contact the TACT Program at: (307) 633-6177


Patient Criteria
Age 18 years of age or older, resident of Laramie County or considered a high risk individual and willing to identify a Primary Care Medical Home (PCMH) to serve as a consistent source of well-coordinated care: TACT Nurse/Care Managers can assist with the following:

  • Obesity
  • Diabetes
  • Medical/Surgical Back Disorder
  • Hypertension
  • Cancer
  • Arthritis and other related disorders
  • Congestive Heart Failure
  • Chronic Obstructive Lung Disease
  • Coronary Artery Disease
  • Stroke
  • Hip Fracture
  • Peripheral Vascular Disease
  • Cardiac Arrhythmia
  • Pulmonary Embolism

Benefits
Increased ability to self-manage your care and health

  • Improved quality of life
  • Improved follow-through with physician recommendations and orders
  • Improved care and health status
  • Improved quality and safety
  • Reduced re-hospitalization rates
  • Reduced hospital costs

TACT Nurse/Care Manager
Registered Nurses are available Monday through Friday

  • Coach you and/or your family regarding the importance of follow-up with your primary care medical home
  • Assist you to create an individualized care plan
  • Teach disease-specific information and medication management
  • Teach you early signs of worsening illness and what to do about them
  • Advocate and encourage you and/or your family to take a lead in your care to have a better quality of life
  • Coach you how to communicate with care providers
  • Behavioral Health Services component
    • If the patient is experiencing anxiety, depression or either condition along with chronic conditions, they may be referred to B-Well— a behavioral health resource support & other community resources.

TACT Program Visit Structure

  • Hospital visits, if hospitalized
  • Phone call within 24-48 hours of referral
  • Follow up questions and schedule/confirm home visit
  • Home visits
  • Create individualized care plan
  • Coaching regarding follow-up visits with providers, medication and disease management
  • Follow up weekly phone visits based on the individual’s needs
  • Coaching regarding provider communication, medication, symptom and disease management