Kentucky Care Coordination for Community Transition

The Kentucky Care Coordination for Community Transition (KC3T) Program provides patient navigation services to help individuals who have had a stroke, transient ischemic attack (TIA) or other neurological condition, to successfully transition back into their community. The KC3T navigator assists individuals and their caregivers to find resources in their community, link them with their healthcare provider and provide education about living with a stroke. These services help improve quality of life after stroke and decrease the number of times individuals need to seek medical assistance. A stroke survivor and caregiver support group meeting is offered each month. KC3T is currently in transition as the program looks for long-term funding sources.


Provide access to medical, social, and environmental services to support community transitions for individuals with neurological conditions and their caregivers living in the Commonwealth of Kentucky

Program Goals

  1. Decrease barriers to accessing healthcare and community resources
  2. Decrease preventable readmissions and emergency department visits
  3. Decrease avoidable healthcare gaps
  4. Increase community integration of individuals with neurological conditions
  5. Improve the Quality of Life (QOL) for individuals with neurological conditions and their caregivers

Support Provided

  1. Assist with health care enrollment
  2. Assist with accessing medications
  3. Assist with obtaining follow-up care (e.g. rehabilitation and primary care) visits.
  4. Assist with accessing community resources (medical equipment, transportation, etc.)
  5. Provide follow-up education on chronic conditions management (e.g. diabetes, HTN, obesity)
  6. Support communication with healthcare system
  7. Support individual discharge plan and track compliance and adherence
  8. Stroke and Caregiver Support Group

For more information about the Kentucky Care Coordination for Community Transition program, contact:

Patrick Kitzman, PhD, MSPT
KC3T Director
Professor & Associate Dean for Research
UK College of Health Sciences
(859) 218-0580

Keisha Hudson
KC3T Coordinator
UK Center of Excellence in Rural Health
(606) 439-3557