Care Transition Program
When being discharged from the hospital, people with new diagnoses or an exacerbation of existing conditions will have changes in their healthcare needs. These may include medications, treatments, and follow-up care from medical practitioners in multiple settings. These changes can often be confusing and challenging to coordinate without assistance.
The Care Transitions Program (CTP) was created to assist people during these times of transition between hospital and home.
We provide individual coaching for clients who fit these criteria. Coaches supply participants with tools to actively co-manage their health care needs and to seek appropriate and timely care.
The Care Transitions coaches are senior- level nursing students from Humboldt State University in their Community Health rotation.
Care Transitions coaching is based on voluntary client participation and is provided free of cost to all clients. St. Joseph Health - Humboldt County offers this program in support of our strategic goal of promoting Healthy Communities.
The Care Transitions Program receives support from the Robert Wood Johnson Foundation's Aligning Forces for Quality Initiative.
The Care Transitions Program is designed to ensure that information is shared between healthcare settings. Also, this program helps clients identify their own needs during the transition from hospital to home.
The success of the program relies on:
- Medication Self-Management
- Personal Health Record (PHR)
- Follow-up visits with a primary health care provider and/or specialist
- Disease process education and “Red Flags”