Care Transitions
Registered nurses (RNs) in the Care Transitions program work with hospital patients during a 30- to 60-day intervention to ensure a safe transition from the hospital to the home. RNs identify ways individuals can avoid hospital readmission and connect them to needed services.
Overview
RNs review the patient’s medication plan and look for additional factors that could lead to readmission, such as chronic health conditions, including COPD, congestive heart disease, hypertension, and diabetes.
Eligibility for this program includes enrollment in a participating health plan, a recent or pending hospital discharge and residence in COAAA’s eight-county service area, including Delaware, Fairfield, Fayette, Franklin, Licking, Madison, Pickaway, and Union.
Basis services and benefits for Care Transitions include:
- RN health Coach Home Visit
- Medication Reconciliation Self-Management
- Social Drivers of Health Assessment
- Environmental Assessment
- Falls Prevention
- Disease Prevention and Education
- Primary Care and Specialist Follow-up
- Referrals for Community Resources