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ESWA

Central MA MetroWest Transitions in Care

i-am-elderly-lg   CCTP

Transitions in Care is coordinated by a group of community-based agencies in the Central MA MetroWest area.  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 Transition Coach will guide you in the following areas:

  • Review care instructions with you after you’re discharged from the hospital emergency department
  • Help you identify questions to ask your doctor
  • Assist you with scheduling timely follow-up care
  • Discuss health warning signs and when to seek immediate care or call 911
  • Give you a booklet to write down your conditions, medications, and questions

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.”

Doctor comment during office visit: “I wish everyone had this Personal Health Record and was this prepared. It would save so much time.”

“I appreciate all that you have done. It has helped me think about what I want to do. You have given me the information on what to do if I am stuck.”
 

Helpful Resources

Read the Central MA MetroWest Transitions in Care brochure here

Coleman Care Transitions Program website

Download the Personal Health Record

Contact us

508-756-1545
800-243-5111
email: eswa-cctp@eswa.org


CCTP

Central MA MetroWest Transitions in Care is a shared effort of

Aging Service Access Point Partners: Elder Services of Worcester Area and Tri-Valley.

 


 The cost of this program is covered by Blue Cross Blue Shield of Massachusetts.

 
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