Care Transitions 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 System - 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:
1. Medication Self-Management
2. Personal Health Record (PHR)
3. Follow-up visits with a primary health care provider and/or specialist
4. Disease process education and “Red Flags”

The Program Process
• Hospital staff, discharge coordinators and CTP coaches identify clients who may benefit from Care Transitions intervention
• A referral is made to the CTP team
• A "Transitions Coach" is assigned and makes contact with the client in the hospital
• The client is provided CTP information and initial coaching is started if the client is interested in the program
• Post discharge, clients receive a followup phone call and/or home visit from coach
• Home visit: Coaches help with medication reconciliation, disease process review, update PHR, and support the client in following up with a clinician/specialist
• Follow-up phone calls at day 2, 4, 7, 14, 30, 60, 90, 120. Coaches answer questions, provide advocacy if necessary, and reinforce the client’s and the clinician’s needs.  Additional home visits are scheduled as needed 
• The client-coach relationship is maintained until goals are achieved

Clients Who May Benefit from a Referral to Care Transitions:
- Those with a new diagnosis impacting health care needs
- Clients with chronic diseases
- Those with multiple medications, new medications and/or changes to existing medication regimen
- Clients with a recent hospitalization or multiple re-admissions
- Clients with multiple Emergency Department visits
- Those with multiple clincial specialists or who are without a Primary Care Provider

Referrals to the program are received from physician’s offices and nurses, physicians, and discharge coordinators from St. Joseph and Redwood Memorial hospitals.

To make referrals, contact:
Care Transitions Office
(707) 445-8121, ext. 5751

Sharon Hunter, RN
Care Transitions Program Coordinator
(707) 445-8121, ext. 5750

If you have any questions about this program or would like more information, please contact:
Sharon Hunter, RN or
Tory Starr, RN
Director of Performance Improvement
(707) 445-8121, ext. 5835