Care Transitions

As a part of our ongoing commitment to improve health and quality of life for the local community, we created our Care Transitions program. The program is designed to assist you or a loved one during the critical period following hospital discharge.

The Importance of Care Transitions

The Centers for Medicare and Medicaid Services (CMS) reports that approximately one in five patients who are discharged from the acute care hospital will be readmitted within the first 30 days following the initial admission. These readmissions are often preventable and are sometimes a result of confusion over medications and how to take them, a lack of education about the cause of the initial admission and awareness of what could cause a readmission and/or a lack of timely follow up with a primary care physician or specialist in the community.

About the Care Transitions Program

Care Transitions is an evidence-based program that focuses on helping reduce preventable readmissions by providing you with the knowledge, confidence and ability to self-manage your health condition. Care Transitions nurses follow, educate and support individuals for 30 days following their hospital discharge. Once you’re back in your home, you can expect a nurse to conduct a home visit and to provide weekly phone calls to help you address any challenges you may encounter as you begin to self-manage your health condition and, in turn, reduce your chances of being readmitted to the hospital.

Care Transition Services

When you’re a part of our Care Transitions program, you won’t feel like a number. You’ll receive personalized care tailored to your exact needs. Some of the most common services provided by Care Transitions include the following:

• Reviewing your medication regimen
• Educating you on your health condition and potential “red flags” for readmission
• Ensuring timely physician follow-up care
• Connecting you with helpful community resources