Transitions in Care is coordinated by a group of community-based agencies across Massachusetts. The program provides personal health coaching to help you manage the transition from the hospital emergency department back to your home. This is an opportunity to work on getting connected with potential health care supports as well as becoming educated on resources available in your community.
- Review and understand your emergency room discharge instructions
- Identify questions to ask your primary care doctor (PCP) or specialist
- Support you with scheduling timely follow-up care
- Discuss health warning signs and when to seek immediate care or call 911
- Gather a list of your medical conditions, medications and questions to bring to your provider appointments
- Provide information on community resources as needed
What to Expect
Once discharged from the Emergency room, a Transitions Coach will contact you.
- The program is a 30-day intervention
- One in-home visit
- Three follow-up phone calls
For Caregivers
Bringing your loved one home from the hospital can be overwhelming. There are many things to remember and do after discharge. Having a good plan in place is the first step. The Transitions Coach’s role is to be resourceful and supportive as you continue to care for your loved one at home.