Care Transitions Program

The Care Transitions Program is designed for clients with Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), or Diabetes who have been recently discharged from the hospital, with a primary goal to support those who would benefit from in-home assessment, treatment, and teaching to work towards improved self-management of their chronic conditions and decrease future hospital visits and admissions.

Eligibility

• A recent (within the last 12 months) hospital admission due to Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), or Diabetes, or at high risk of hospitalization as a result of these chronic conditions
• Willingness to learn disease self-management strategies or have a caregiver looking to better understand and manage the disease on the client's behalf