Home Based Transition Care

HOME-BASED TRANSITION CARE TEAM

Intensive in-home support for those with COPD/CHF discharged from the hospital or at risk of hospitalization.

The program for those with congestive heart failure and COPD is delivered through home visits, telephone calls, and other virtual care based on patient needs. Patients are given a phone number that they can call during business hours if they need non-urgent assistance or advice. We work with primary and interprofessional healthcare providers, community partners, and patients/ caregivers to strive for disease stability, decrease hospital visits, and support optimal quality of life.

This program is for

Patients with CHF and COPD.
• Being discharged from the hospital
• At risk for hospitalization
• Unstable symptoms or unable to self-manage
• Newly diagnosed with these conditions and interested in more information

Program Services

We provide support including:
• Assessment/Monitoring
• Adjustments to care plan to encourage disease stability
• Education to patient/caregivers about their disease and how to self-manage
• Development of action plans

The program is delivered through home visits, telephone calls, and other virtual care based on patient needs. Patients are given a phone number that they can call during business hours if they need non-urgent assistance or advice. We work with primary and interprofessional healthcare providers, community partners, and patients/ caregivers to strive for disease stability, decrease hospital visits and support optimal quality of life.

Goals for Participants

Services are generally provided until symptoms stabilize and the patient/caregiver is comfortable with management.
This can typically be accomplished within 4-6 weeks following a patient’s discharge or from the first visit.
Some patients find a single visit from our team meets their needs.