[google-translator]

Community Based Transitions in Care Program
Home
• About Us • Programs and Info •
Community Based Transitions in Care Program

We’ve partnered with Blue Cross Blue Shield of Massachusetts, an independent company, to provide eligible Blue Cross Medicare Advantage members with a no-cost Transition in Care program. During this four-week program, a Transitions Coach supports patients with complex care needs by teaching them self-management skills that will ensure their needs are met during their transition from hospital to home. Patients enrolled in the program are much less likely to be readmitted to the hospital, and more likely to achieve self-identified personal goals when it comes to symptom management and recovery.

We’ve partnered with the following agencies to support this Blue Cross benefit:

Tri-Valley, Inc.
Access Care Partners (formerly WestMass ElderCare)
AgeSpan
Somerville/Cambridge Elder Services, Inc.
Mystic Valley Elder Services, Inc.
Greater Springfield Senior Services, Inc.
Bristol Aging & Wellness, Inc.
Old Colony Elder Services, Inc.
SeniorCare, Inc.
Elder Services of Cape Cod and the Islands, Inc.
Greater Lynn Senior Services, Inc.
LifePath, Inc.
Coastline Elderly Services, Inc.
Highland Valley Elder Services, Inc.
South Shore Elder Services, Inc.
Aging Service of North Central Mass
Boston Senior Home Care
Central Boston Elder Services, Inc.
Springwell, Inc.

Once enrolled, your transitions coach will guide you in the following areas to avoid another ED visit:

Review and understand your ED discharge instructions
Identify questions to ask your primary care provider (PCP)
Assist you with scheduling timely follow-up care
Discuss health warning signs and when to seek immediate care or call 911
Gather a list of your conditions, medications, and questions to bring to your provider

What to Expect

It is a 30-day program
One in-home visit
Three follow-up phone calls

For Caregivers

Bringing your loved one home from the hospital can be overwhelming. There are so many things to remember and to do. Having a good plan is the first step. Our Transitions in Care Coaches will help you with all of this.

Consumer Testimonials

“Would recommend my insurance plan to everyone based on the personalized care shown when I had health problems.”

“Melissa was great & was great to have additional support as I recover. She informed me of services that were available.”

“Sherrie followed up to be sure a referral was being implemented; and I am now getting primary care after 3+ years without it.”