Care between visits.
Confidence across
every transition.
Life happens between appointments. Trinity Care Continuum connects patients, families, and healthcare partners through proactive care management and compassionate support.
One Patient. One Team. One Coordinated Plan.
At the center.One person. A connected circle of care.
Connecting the people who care for you.
Every patient deserves
a medical home.
Care can become fragmented when patients move between the hospital, skilled nursing, home health, and everyday life. Trinity helps connect the plan—so patients and families have support beyond a single visit or episode.
Our nurse practitioner-led model brings care management, clinical oversight, medication coordination, and patient education together around the needs of each person. When a primary care relationship exists, we strengthen it. When one is missing, we help establish appropriate access.
“Care does not stop when
the episode ends.”
Support for the whole person.
A plan that stays connected.
Programs are tailored to clinical needs, patient goals, eligibility, and the care already in place.
Chronic Care Management
Ongoing support for people living with multiple chronic conditions. We help patients understand their care plan, navigate medications and follow-up, and stay connected to their clinical team.
CCM · Care planning · Medication coordinationLearn more 02 / EMOTIONAL WELL-BEINGAnxiety and/or Depression
Emotional health belongs in the care plan. This program brings screening, regular outreach, care coordination, and connection to appropriate resources into the management of chronic illness.
Screening · Patient engagement · Caregiver supportLearn more 03 / COMFORT & QUALITY OF LIFEPalliative Care
Compassionate support for people living with serious illness. We focus on symptom concerns, goals of care, family communication, and coordination with the patient's treating providers.
Serious-illness support · Goals of care · NavigationLearn more 04 / STRONGER TRANSITIONSTransitional Care Management
Support after a hospital or qualifying facility discharge, including timely outreach, medication reconciliation, follow-up coordination, and help navigating the next phase of recovery.
TCM · Post-discharge follow-up · Care handoffsLearn moreTelehealth for all
of Texas.
Trinity's care is delivered entirely by telehealth, so we can support patients, families, and healthcare partners anywhere in Texas, with no travel required.
- DFW
- Houston
- San Antonio
- Austin
- El Paso
- Corpus Christi
- RGV
- Lubbock
- Amarillo
- Midland–Odessa
- Abilene
- San Angelo
- Waco/Temple/Killeen
- Bryan Cstat
- Tyler–Longview
- …and everywhere in between
Shared patients.
Shared purpose.
We strengthen the relationships patients already trust. Trinity works alongside your team to support follow-through, identify care gaps, and keep the plan connected across settings.
Better care begins
with a conversation.
Refer a patient, ask about a program, or explore a partnership. Our intake team can help identify the right next step. Telehealth across all of Texas.