This is a FREE program for Medicare beneficiaries to aid in the transition from hospital to home. This program aims to educate clients on the following risk factors for hospital readmission:
- Recognize signs that conditions are becoming worse and ways to self manage.
- Understand and manage medications better.
- Make a plan for a follow-up appointment with the primary care physician and ensure proper transportation is arranged.
- Assist with creating and maintaining a personal health record.
The client will receive the following services from a transitions coach during the 4-week program.
- A one on one visit while the client is in the hospital allowing them ask questions about the program.
- A home visit following hospital discharge to review and further educate the client on risk factors for readmission.
- Three follow-up phone calls over a thirty day period to provide support during the client’s transition and provide education as needed.
A Transitions Coach will also work with the client, and any other persons they identify, in ensuring access to appropriate community-based long-term supports.
The goal is to provide you with skills for effective health self-management. There is no-cost to individuals to take part in this program. Appalachian Agency for Senior Citizens partners with local hospitals including, Clinch Valley Medical Center, Buchanan General Hospital, Russell County Medical Center and Carillion Tazewell Community Hospital.
If you have any questions, please contact: Appalachian Agency for Senior Citizens at 276.964.4915 or email [email protected]. For additional information on the Care Transitions Project please visit: http://www.innovation.cms.gov/initiatives/CCTP/