TRANSITIONS IN CARE COACHING
Returning home from a hospital stay can feel overwhelming. There are often new instructions, medications, and follow-up appointments to manage. Having a clear plan can make this transition easier.
Coastline’s Transitions in Care Coach provides guidance during this period. This four-week Blue Cross Blue Shield of Massachusetts benefit helps you build the skills and confidence you need to manage your health at home. Support includes medication management, preparing for follow-up medical visits, creating a personal health record, and recognizing early warning signs of health concerns.
The Transitions Coach works with patients who have complex care needs—as well as their caregivers—to ensure support is in place from hospital to home. People who participate in this program are less likely to return to the hospital and more likely to meet their own recovery and symptom-management goals.
ONCE ENROLLED
Your Transitions Coach will help you return home safely and reduce the chance of an emergency department (ED) visit by supporting you with:
- Reviewing and understanding your ED discharge instructions
- Preparing questions to ask your primary care provider (PCP)
- Scheduling timely follow-up appointments
- Discussing health warning signs and when to seek immediate care or call 911
- Organizing your list of conditions, medications, and questions to bring to medical visits
WHAT TO EXPECT
The program lasts 30 days and includes:
- One in-home visit
- Three follow-up phone calls
FOR CAREGIVERS
Bringing a loved one home from the hospital can be stressful. There may be new responsibilities and information to manage. A Transitions in Care Coach is here to guide you through each step and ensure you have a clear plan moving forward.
HELPFUL RESOURCES
Your Transitions Coach can help you complete a Personal Health Record, which keeps important health information in one place.
For more information, visit the BCBS Member Support & Assistance page and scroll down to Transition in Care Program under Additional Programs.
This program is open to eligible Blue Cross Medicare Advantage members through a partnership with Elder Services of Worcester Area.