Care Transitions Program
The Care Transitions Program is designed to encourage vulnerable older patients and their caregivers to assert a more active role during care transitions. The program is targeted at a population of patients identified to be at increased risk of experiencing readmission to the hospital within 30 days. By empowering the patient, the intent is to reduce the risk and maintain the patient in the community for longer periods of time.
What is a Transition Coach?
The goal of the Transition Coach program is to provide patients with the tools and support to promote confidence, knowledge and self-management of their condition as they move from hospital to home.
In 2011, St. Mary Mercy Hospital became the first hospital in the area to develop a hospital-based Transition Coach program.
The Transition Coach guides the patient in the following areas:
- Understanding of current medications and completion of the Personal Health Record
- Use of a medication management system and maintenance of one true medications list
- Scheduling of doctor appointments
- Effective communication with doctor
- Partnering with doctor on collaborative goal setting
- Involvement in health care decisions
- Identification of early warning signs and when to call a health care professional
- Working with an expanded Transition Team approach, if necessary, that includes a visiting nurse, physical therapist and Senior Alliance Resource Specialist
In the News
Our Transition Coach program has been featured in the Detroit Free Press and our Life & Health community newsletter.
For more information, download the brochure, or call 734-655-2308.