TRANSITIONS IN CARE PROGRAM
The Transitions in Care Program provides short-term support to individuals returning home following an emergency department visit or hospital stay. The program is designed to help participants better understand their health needs, navigate the healthcare system, and connect with community resources that support their independence and well-being.
How the Program Works
A trained care professional will work one-on-one with participants for approximately 30 days following discharge. Support may include:
- Reviewing discharge instructions and follow-up recommendations
- Helping participants prepare for appointments with primary care providers and specialists
- Discussing medications and encouraging questions for healthcare providers
- Identifying warning signs that may require medical attention
- Connecting participants with community resources and support services
- Encouraging self-management skills and confidence in managing health conditions
What Participants Can Expect
Participants typically receive:
- One in-home visit or telephonic visit, when appropriate
- Several follow-up telephone contacts
- Assistance identifying unmet needs and available community resources
- Support with care coordination and healthcare navigation
Benefits of Participation
The program helps individuals:
- Feel more confident managing their health after returning home
- Better understand their medical conditions and treatment plans
- Improve communication with healthcare providers
- Access community resources that support health, safety, and independence
- Reduce barriers that may affect recovery and well-being
For Caregivers
Family members and caregivers often play an important role in a successful recovery. Program staff can help caregivers understand discharge instructions, identify community supports, and connect with resources that may assist them in their caregiving role
For more information please visit: Member Support & Assistance Program | Blue Cross Blue Shield of MA