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Transitions Program

What is the Transitions program?

Transitions is a community-based resource program designed with the specific goal of preventing patient re-hospitalization within the first 30 days following discharge from a hospital or other care facility. The program is offered free of charge as a way for Hospice of the South Coast to give back to our community and to the facilities we work with.

Why is Transitions necessary?

Preventing re-hospitalization is a primary goal for both the patient and the facility. Re-hospitalization often occurs when a patient has a recurrence of pain or other symptoms, typically as a result of one or more of the following:

  • Unfilled prescriptions,
  • Misunderstanding physician orders,
  • Inability to transport themselves to doctor’s appointments,
  • Lack of education regarding their condition

Our professional medical staff gets involved shortly after the patient arrives home to ensure these issues will not be the cause of a readmission.

How much does the program cost?

The Transitions program is offered completely free of charge to both the patient and the facility. We consider it a privilege to allocate some of our resources to be able to contribute to the improved health and well-being of our community.

How does the Transitions program work?

Each patient is assigned a nurse and a social worker upon discharge. Within 48 hours, the patient is contacted to discuss their specific needs and concerns in transitioning to home life following their hospital stay.

The nurse will assist with tasks such as:

  • Having prescriptions filled,
  • Scheduling follow-up appointments with the patient’s primary care physician,
  • Answering questions or concerns about medications or treatment.

The social worker will be available to provide guidance for other things, including:

  • Completing a Medicaid application
  • Advance care planning
  • Arranging patient transportation to a medical appointment

The nurse/social worker team will continue to follow up with the patient for their first 30 days following discharge from the hospital. The patient and their loved ones can rest assured that the change from hospitalization to home care will be a smooth process, knowing that we will do everything in our power to prevent re-hospitalization.

How do I find out more?

To find out if you, a loved one, or a patient is a candidate for the Transitions program, you can reach out to us through either of the following:

Mobile: (888) 982-8630
info@hospiceofsouthcoast.com

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