“The Care Transition Program is designed for patients who want to stay out of the hospital.”
“Patients who participate in the 30-day Care Transition intervention are significantly less likely to be readmitted to the hospital.”
“A certified Transition Coach will visit you in your home within 1 week of discharge from the hospital, and will contact you weekly for the next 3 weeks. If you are interested, the next step will be for the Transition Coach to visit you here in your hospital room prior to discharge.” (NOTE: Provide the patient with a Meet Your Care Transition Coach card).
“The Transition Coach does not fix problems and does not provide skilled care. Rather, the Transition Coach will model and facilitate new behaviors, skill transfer, and communication strategies for you and your caregivers to build confidence that you can successfully respond to common care transition problems, such as medication changes, scheduling follow-up appointments with new or existing providers, coordinating the use of community resources, etc.”
Next Steps: Once the patient has been introduced to the CT Program and has expressed an interest in participating, please submit a referral by phone (405) 271-8767, fax (405) 271-2626, or email firstname.lastname@example.org, or meet directly with Transition Coach, as available.