🌟 Care Transitions

Your bridge from hospital to home.

Leaving the hospital or a skilled nursing facility can feel overwhelming — but you don’t have to do it alone. Care Transitions is a 30-day, evidence-based program designed to make your move back home smoother, safer, and healthier. Our goal is simple: help you heal at home while reducing the risk of hospital readmission.

💡 What to Expect from Care Transitions

Your journey begins with personalized support every step of the way:

• Pre-Discharge Visit – A trained Community Care Coach meets you at the hospital or skilled nursing facility before you go home.

• Home Visit – Within 48–72 hours of discharge, you’ll receive an in-home visit to check on your recovery and help you settle in.

• Care Coordination – We’ll share updates with your primary care provider to ensure your medical team is always in the loop.

• Community Connections – Referrals to the Aging & Disability Resource Center (ADRC) for local resources and ongoing support.

• Follow-Up Calls – Regular check-ins to review:

  • Medication management 📋

  • Physician follow-up appointments 🩺

  • Community-based provider needs 🏡

  • Signs and symptoms to watch for 🚨

  • A personal health booklet to track your progress and questions.

✅ Program Benefits

By joining Care Transitions, you’ll gain:

• Access to long-term care resources that fit your needs.

• Improved health outcomes with professional support and guidance.

• Reduced caregiver burden, giving families peace of mind.

💲 Costs & Eligibility

Eligibility may vary depending on the contracting entity, but in most cases there’s no cost to participate. The program is also available on a private pay basis for those who don’t qualify under standard criteria.

📞 Want to learn more? Call us today at 260-745-1200.

✨ With Care Transitions, you’re not just discharged — you’re supported, guided, and empowered to thrive at home.