Transitional Care Programs

Care Transitions
A Care Transitions coach visits with a patient in the hospital

It can be really difficult to leave a nursing home and move back into the community, especially if you no longer have a home to return to. It’s a transition that you can’t do alone.

It’s also challenging to move from one care setting to the next as you’re recovering from an illness or surgery. Keeping track of medications, doctor’s appointment, therapy regimens and discharge instructions can become overwhelming - especially as you move from the hospital and then perhaps to a nursing facility, and then back home. That’s when things can go haywire and you land right back in the hospital.

As part of our mission to help people remain independent in their homes, Council on Aging offers Transitional Care programs that address these challenges.

Through home visits, health coaching, connections to community resources and coordination of services, Council on Aging helps thousands of people successfully transition from one care setting to another. In other words, we can help you get home and stay home.

In the process, we’re helping our whole health care system by reducing unnecessary hospital admissions and nursing home placements.

Learn more about transitional care options:
Care Transitions
Community Transitions and Home Choice

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