ESWA

Central MA MetroWest Transitions in Care


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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.

 


 

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.”
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

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: 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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