Care Transitions

1. What is Care Transitions?

Care Transitions is a 30-day evidence-based program that supports individuals of any age transition from a hospital or skilled nursing facility back to their home, reducing hospital readmissions.

2. What services can I receive from Care Transitions?

Services depend upon the contracting entity. In general, participants in the Care Transitions program will receive a visit from a trained Community Care Coach in the hospital/skilled nursing facility prior to discharge, a home visit within 48-72 hours of discharge, written communication with your primary care provider following home visit, referral to the AIHS Aging & Disability Resource Center (ADRC) for community-based resources as needed, follow-up phone calls to review patient needs including: Medication Management; health booklet to record information and questions for your healthcare team; physician follow-up visits; community-based provider needs; & review of signs and symptoms to avoid readmission.

3. Are there eligibility requirements or costs to participate?

Eligibility requirements depend upon the contracting entity; in general, there is no cost to participate. The program is also available on a private pay basis. For more information, please call 260-745-1200, extension 328.