Care Transitions is a free service from trained a Coleman or other Care Transitions Coach, and involves short term services, including one home visit, and two followup calls over a period of thirty days. Care Transition Coaches work closely with the consumer, their family and other informal supports, and medical practitioners and facility staff. The goal of Care Transitions is “Getting Home and Staying Home.”
A Care Transitions Coach can
- Assist you when you change care settings: home to a hospital, hospital to rehab, rehab to home, home to your physician’s office, etc.
- Work toward the goal of keeping you out of the hospital
- Provide assistance with medications, understanding the “red flags’ of your medical condition, preparing for your primary care doctor or specialist appointment. A personal health record is also provided for you to use for all your appointments.
- Provide information about and referral to other programs, as needed.