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Continuity of Care

Updated: Jul 4, 2018



Continuity of care is crucial when a patient is hospitalized and transfers back home. Confusion, frustration and miscommunication often take place after discharge from the hospital, rehabilitation facility or skilled nursing facility and patients and caregivers commonly are uncertain as to what to do next. Ask yourself these simple questions and you will know if a Transitions Care Coach is right for you.

  • Do you understand the diagnosis?

  • What medications have been prescribed?

  • Have there been any changes made in medications since the hospitalization?

  • What are the warning signs that led you or your loved one to the hospital?

  • What precautions need to be taken after the discharge?

  • Do you fully understand the test results?

  • Have follow-up appointments been made with the primary care physician or specialist?

  • When will physical therapy, occupational therapy, speech therapy, or wound care begin?

A care transitions intervention program fully supports this transition by working directly with the patient and family caregiver to provide a more active role in their care. Modeling and facilitating new behaviors, skills transfer, and communication strategies helps to build confidence so that patients and family caregivers will be able to respond to common problems that arise during transitions. A home visit within 24 to 48 hours of hospitalization, rehabilitation or a skilled nursing home discharge will be conducted and four weekly follow-up phone calls will be made to increase self-management skills and personal goal attainment for all.


Over the course of thirty days, the Transitions Care Coach will listen to and honor the client’s goals, preferences, observations and concerns. The result, an empowered, safe individual with clarity of medical condition. The Care Transitions Intervention program facilitates communication and continuity of care plans across settings empowering and educating clients and caregivers to become more independent. There is no cost to you for a Transition Care Coach. Overall, the Care Transitions intervention program will help prevent a hospital readmission and lower healthcare costs.

by Jolene Martel Schwartz, LMSW


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