Care Transitions

Piedmont Senior Resources (PSR) offers Care Transitions.This program aids in the transition from the hospital to home and aims to educate clients on the following risk factors for hospital readmission.

Hospitalization is sometimes planned and sometimes unexpected but it is always confusing and stressful. PSR offers an evidence based Care Transitions Program to assist patients and their families/caregivers in a safe return home from the hospital or rehabilitation center.

The program is designed to support patients in directing their own health care and preventing unnecessary readmissions to the hospital or emergency room. This is a 30 day intervention provided by a trained health coach and consists of a visit before discharge, a home visit (within 72 hours of discharge) and at least three follow ups by phone. Areas covered include personal goals for recovery, follow up medical care, medication issues, and warning signs with regard to health conditions.

Call before your next scheduled admission or before your discharge. For more information about this program, please contact PSR.