> Care Transitions Program

The Community-Based Care Transitions Program aims to improve coordination of services upon discharge. The goal is to help you transition home successfully after leaving the hospital. With the support of local hospitals and senior care organizations there is “no cost at all to the consumer” for care transitions.

We work collaboratively with area hospitals to ensure smooth care transitions for elders. Our area hospitals are: Anna Jaques Hospital in Newburyport, Holy Family Hospital in Methuen, Holy Family Hospital at Merrimack Valley in Haverhill, Lawrence General Hospital in Lawrence, Lowell General Hospital in Lowell and Lowell General Hospital – Saints Campus in Lowell.

The Process

During the initial 4-weeks after your discharge, you will be assigned a Transitional Coach who will provide: A personal health record designed to help you manage your health condition, home visits and follow-up phone calls. The coach will provide support during the transition from hospital to home. In addition the program will provide tools and support that promote knowledge and self-management of your health. You will receive assistance with transitions across all health care settings which include: Primary care physician (PCP) follow up appointments, arranging routine referrals and interventions, care coordination arrangements and medication management including reconciliation. All services provided through this Program aim to reduce avoidable hospitals re-admissions.

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