Care Transitions


Care Transitions Healing@HomeThe Care Transitions program works with Medicare beneficiaries who have recently been discharged from a local hospital and are at high risk for readmission.

The program targets Medicare Fee-for-Service beneficiaries who have been recently hospitalized and are at the risk for re-admission due to chronic diseases, a history of repeat admissions and/or psycho-social risk factors.

Beneficiaries are visited in their home within 24-48 hours of hospital discharge to ensure they have made their follow-up doctor’s appointments, can manage their medications, understand the red flags of the disease and have necessary social supports. They are also given a personal health record to keep track of all of their critical health information.

After the initial home visits, beneficiaries receive a series of follow up telephone reassurance calls for 30 days to ensure their transition home is going smoothly and that they don’t re-admit to the hospital.

Care Transitions Services Include:

  • One face-to-face visit at the hospital
  • Minimum of one follow up visit in the home within 24-48 hours of discharge with a focus on:
    • Medication reconciliation
    • Connecting patient to primary care physician
    • Use of a personal health record
    • Education on disease red flags
  • Telephone reassurance calls for a period of 30 days
  • Home safety check
  • Behavioral Health Screening
  • Social support such as transportation to medical appointments provided by AmeriCorps Volunteers

This program is only available to patients at participating hospitals.

Contact Us Today

For more information about Care Transition and the Healing@Home program, call the Senior HELP LINE at 602-264-HELP.

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