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Transitional Care Nurse Program

Transitional Care Nurse Program

Rita Demko, St. Mary Medical Center Transitional Care Nurse, meets with heart failure patients to perform an assessment and develop a plan that is specific to the individual patients' care needs.

She then coordinates the patient's plan across the continuum of care, interacting with a multidisciplinary team which includes home care providers, skilled nursing facilities, and family caregivers. 

The patient plan also includes the promotion of self-care, in which Rita provides disease-specific education using teach back methods to the patient.

Working right alongside the patient and family, Rita also participates in discharge planning to achieve the best support for the patient.

Please click here to access the St. Mary Self-Care Patient Handbook that will help guide you through living with heart failure.

Rita Demko, Transtional Care Nurse

She will then follow up post-discharge by phone to provide encouragement and evaluate the outcome of the entire patient experience.

Rita is available Monday through Friday from 8 a.m. until 4:30 p.m. She can be reached by phone at 215-710-4747, or by e-mail at and will work to accomodate your schedule. 

Please feel free to use Rita as a resource for your questions concerning diet, fluid restrictions and weight tracking. She is here to help you.