Central MA MetroWest Transitions in Care

i-am-elderly-lg   CCTP

Our team of Transition Coaches are helping patients avoid hospital readmission and have better health at home.



Once enrolled, your Transition Coach will guide you in the following areas:

  • Review my discharge instructions with me after being discharged from the hospital
  • Help me identify questions I have for my doctor
  • Improve my ability to schedule timely follow-up care
  • Improve my knowledge of my symptoms related to my conditions and when I should seek medical advice
  • Provide me with a booklet where I can write down my medical conditions, medications that I am taking at home, and any questions I have for my doctors or nurses


What to Expect

  • It is a 30-day program
  • One in-hospital meeting
  • One in-home visit
  • Two 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 Transition Coaches will help you with all of this.




“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.”
PCP comment during office visit: “I wish everyone has this (PHR) and was this prepared. It would save so much time.”
”Coaching has been wonderful, I feel like I know I can do this now.”
“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




Central MA MetroWest Transitions in Care is a shared effort of

Aging Service Access Point Partners: Bay Path Elder Services, Elder Services of Worcester Area, Greater Springfield Senior Services, HESSCO, Montachusett Home Care, Springwell, Tri-Valley and Western Mass Elder Services.  Medical Partners: Metro-West Homecare & Hospice, Tenet Healthcare System, UMass-Memorial Medical System and Baystate Wing Hospital.


This is a Medicare benefit. There is no cost to you.

Funded by the Centers for Medicare and Medicaid Services under section 3026 of the Affordable Care Act

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