Care Transitions Program

When being discharged from the hospital, people with existing conditions might have changes in their health care needs. These challenges can be confusing to coordinate without assistance. The Care Transitions Program was created to assist people during these times of transition between the hospital, and the home. This program is provided free of cost.

The Program Process:

Staff at the hospital identify and refer patients to coordinators who determine if they are appropriate for the program. A referral is made, then the Care Transitions Coach evaluates the patient in the hospital prior to discharge. The patient is provided with the care transitions information, and the initial coaching is started if the patients enrolls in the program. If enrolled, the coach will then conduct a home visit 24-48 hours after discharge. At the home visit, the coach will develop interventions, help with medication reviews, teach patient about their disease process, and support the patient in follow up with their physician. A follow up phone call for coach occurs 7-10 days after the home visit and then 30 days after post discharge for hospital.

Patients who are eligible for care transitions:

  • A patient with a chronic disease ( CHF, COPD, Pneumonia, Diabetes, Chronic UTI's)
  • A new diagnosis impacting health care needs
  • Patients who have had multiple Emergency Department visits
  • Patients with a recent hospitalization
  • Has multiple medications, and/or changes to existing medication regimen

If you have any questions about this program, please ask for the Care Transitions Team at Community Health Center.

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Counties Served:

Fulton, Montgomery, Herkimer, Schoharie, Saratoga, Hamilton, and Warren Counties