Community Based Transitions in Care Program
Transitions in Care is coordinated by a group of community-based agencies across Massachusetts. The program provides personal health coaching to help you manage the transition from the hospital emergency department back to home. It’s a great way to get connected to health care support and resources in your community.
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.
Testimonials
“Your visit was very helpful to me. I don’t feel powerless.”
“The program laid out everything that I needed to do. You explained that it was up to me to handle my own recovery.”
Spouse: “It is very helpful to talk freely with someone without being judged.”
Helpful Resources
Coleman Care Transitions Program website
Download the Personal Health Record
Contact us
508-756-1545
800-243-5111
email: eswa-cctp@eswa.org
