Healthy Transitions

Your Health is a Gift. None of us can predict when our health may change unexpectedly. At any moment, you may suddenly require an emergency- room visit, hospitalization, unplanned surgery or simply the need for additional in-home support. A change in one’s health can often result in a new diagnosis, new medical specialists, new medications or even a short rehab stay after hospitalization. Where can you turn for help to navigate today’s complicated health care system and find the help you need?

Healthy Transitions™: A Program That Can Help

Your Senior Living Community, in partnership with Visiting Nurse Health System, provides its residents with access to an on-site Care Coordination Coach who specializes in helping recently hospitalized residents to safely transition back home.

Your Care Coordination Coach will:

• consult with you and/or your family prior to your return home to discuss what to expect and to review your safe transition plan
• communicate and coordinate with hospital, physicians and/or rehab staff regarding the services necessary for your successful return home, and coach you about your responsibilities for your care
• visit with you upon your return home to ensure your safe transition plan is being followed

By successfully understanding how to better manage your health concerns, you can decrease the likelihood of re-hospitalization. Your Care Coordination Coach from Visiting Nurse Health System will be there to help.

Connecting With a Healthy Transitions™ Coach

Healthy Transitions is a program brought to you in partnership with your Senior Living Community and is available to all residents. Participation is strictly voluntary. Whether you are in the hospital, rehab or at home, a Healthy Transitions Care Coordination Coach in your community is available to work with you.

Your Coach

Your Care Coordination Coach will work with you to help you better
understand how to manage your health and be your own advocate. The
more informed you are about your health and the care you may require,
the better that care can be.

Each Coach is a nurse trained to:

• teach you more about your disease
• coach you to recognize any changes in your health that would
  indicate a need to contact your physician
• teach you about your medications and ensure you take them as
  directed
• coach you on how to work with your doctors and other care providers to maximize your health
• help you to organize your health information in a Personal
  Health Record

Visiting Nurse Service Area