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Transitions In Care

Seamless Care Transitions: From Hospital to Home

with Circle of Care St. Louis

Transitions in Care 

 

The Transitions in Care Services at Circle of Care St. Louis is designed to support individuals and their families as they navigate the critical period following a discharge from the hospital emergency department. Through personalized health coaching and comprehensive care coordination, our Transition Coaches ensure a smooth transition back to home, connecting participants with vital healthcare support and community resources.

 

Program Features:

 

  • Personal Health Coaching:

    • Post-Discharge Review: Transition Coaches review discharge instructions with participants to ensure they understand their care requirements after leaving the hospital.

    • Healthcare Navigation: Coaches assist participants in formulating pertinent questions for their doctors, enhancing communication and care outcomes.

    • Follow-Up Care Scheduling: Coaches help schedule timely follow-up appointments, crucial for recovery and preventing readmissions.

    • Health Monitoring: Participants are educated on recognizing critical health warning signs and understanding when to seek immediate medical attention or call 911.

    • Resource Toolkit: Each participant receives a booklet to record their health conditions, medications, and any questions they might have, facilitating effective communication with healthcare providers.

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  • Services Structure:

    • Duration: The services last 30 days, providing focused support during the initial post-discharge period.

    • In-Home Visit: Within the first week after discharge, a comprehensive home visit is conducted to assess the home environment, discuss the transition plan, and address any immediate concerns.

    • Follow-Up Communication: Three follow-up phone calls are made over the course of the services to monitor progress, adjust care plans as necessary, and provide ongoing support.

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  • Support for Caregivers:

    • Recognizing the challenges faced by caregivers, our Transition Coaches provide guidance and support to manage the complexities of care at home effectively. This includes educating caregivers on medication management, emergency procedures, and daily care routines to ensure they feel confident and prepared.

 

What to Expect:

  • 30-Day Program: Designed to provide intensive support following hospital discharge.

  • One In-Home Visit: Conducted by a Transition Coach to set up a care plan and ensure the home environment is conducive to recovery.

  • Three Follow-Up Phone Calls: These calls assess ongoing needs, provide additional resources, and adjust care plans as necessary.

 

For Caregivers: Bringing a loved one home from the hospital can be overwhelming. Our Transitions in Care Coaches are here to assist with creating a manageable and effective care plan. From understanding medication management to recognizing when additional care is needed, our coaches provide the necessary support to ensure caregivers are not alone in this journey.

 

The Transitions in Care Program at Circle of Care St. Louis is committed to ensuring that individuals transitioning from hospital to home receive the support and resources necessary to achieve a successful recovery. By leveraging the expertise of our Transition Coaches and focusing on comprehensive care management, we aim to enhance patient outcomes, reduce the likelihood of hospital readmissions, and improve overall quality of life for participants and their families.

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