Bluegrass Care Navigators has been awarded $97,500 by Saint Joseph London through the CommonSpirit Health Community Health Improvement Grant to expand its Bluegrass Transitional Care (BTC) program with a new partnership with Saint Joseph London. This expansion will strengthen the support for high-risk patients transitioning from hospital to home in Laurel, Jackson, and Whitley Counties. 

This expansion addresses a critical need for improved access to care and chronic disease management among individuals facing complex medical, behavioral health, and social challenges. Through this partnership, BTC will deliver evidence-based transitional care interventions designed to help patients safely navigate the transition from hospital to home while reducing preventable hospital interactions, including readmissions. 

The program will enroll up to 181 patients identified as high-risk due to chronic illness, behavioral health conditions, or social barriers. Each participant will receive a comprehensive 30-day bundled care plan that includes hospital bedside enrollment, three in-home visits from a nurse or care coach, and unlimited 24/7 phone support. 

Core services provided through BTC include medication reconciliation, disease specific education using the teach-back method, and assistance scheduling follow-up appointments within seven days of discharge. Patients will also be connected to vital community resources such as transportation assistance, tobacco cessation programs, nutrition support, and behavioral health treatment. 

By strengthening the continuum of care, BTC ensures patients and caregivers have the tools, knowledge, and access needed to manage chronic and serious conditions, including diabetes, cancer, cardiovascular disease, and substance use disorders. The program is designed to achieve measurable outcomes, including a reduction in hospital readmissions and improved patient engagement in ongoing care. 

Program goals include: 

• A reduction of 15 percent or more in 30-day hospital readmissions among participants 
• At least 90 percent of patients receiving timely medication reconciliation 
• At least 85 percent securing a primary or specialty follow-up appointment within seven days 
• At least 80 percent demonstrating teach back competency in self-management of their condition 
• At least 70 percent connected to at least one additional healthcare or social service resource 

Continuous evaluation throughout the 12-month grant period will track enrollment, service delivery, and patient outcomes to ensure the program’s effectiveness and impact. 

“This grant strengthens our ability to serve individuals and families across our community with the care, comfort, and support they deserve,” said Liz Fowler, President of Bluegrass Care Navigators. “It reflects the power of partnership in ensuring no one must face serious illness alone. This investment supports Bluegrass Care Navigators’ mission to deliver patient-centered care with excellence and compassion. We are thankful for this partnership and the opportunity to expand access to critical services for those who need them most.” 

The expansion of Bluegrass Transitional Care directly advances Saint Joseph London’s community health priorities by improving access to care, reducing avoidable hospital readmissions, and enhancing long-term health outcomes for some of the region’s most vulnerable patients. 



About Bluegrass Care Navigators 
Established in 1978, Bluegrass Care Navigators (BCN) provides hospice care in 32 counties across northern, central and eastern Kentucky. As a mission-driven, nonprofit agency, BCN supports those facing serious illness or chronic disease with both long and short-term hospice care, palliative care, transitional care, PACE (Program for All-Inclusive Care for the Elderly), and grief counseling services. For more information on services available by county, visit bgcarenav.org or call 855.492.0812. 

About Saint Joseph London 
Saint Joseph London is a 150-bed full-service hospital located in London, KY. Established in 1926, the facility serves patients from southeastern Kentucky, including those from Clay, Laurel, Jackson, Whitley, Knox and Pulaski counties. The current $152 million regional hospital opened in 2010, and offers all private patient rooms, with most overlooking a small lake and garden on the 52-acre healing environment.