> Care Transitions Program

The Community-Based Care Transitions Program aims to improve coordination of services upon discharge from acute care settings to the community. The goal of this program is to work collaboratively with community partners to ensure comprehensive transitions of care with a focus on patient centered planning.

The Process
During the weeks following discharge, you will be assigned a Transition Coach who will conduct home visits and/or follow-up calls. The program will provide tools that promote self-management of your health. One of these tools is a Personal Health Record, which is designed to help you manage your health condition(s). In addition, the Transition Coach will assist you with coordinating follow-up appointments with providers, arranging routine referrals and interventions, and facilitating medication reconciliation. All services provided through this program aim to reduce avoidable hospital re-admissions.

For more information about the Care Transitions Program, contact our Age Information Department at 1-800-892-0890