Benefits of the Care Transitions Program include:
- Elders discharged from an acute or rehabilitation setting will be referred to a coordinated medical/social services team that coordinates access to needed services to support the patient's successful transition home.
- Care Transitions patients with serious chronic diseases will see a primary care physician within five days of hospital discharge -- whether this service is directly provided by Dr. Beringer as the Kane Clinic physician, or arranged and coordinated by the Kane advanced registered nurse practitioner (ARNP) with the patient's existing primary care physician.
- Care Transitions patients with serious chronic diseases will have their medications reconciled by the ARNP within two days of discharge.
- Care Transitions patients with serious chronic diseases, as well as their caregivers, will have access to a care manager within a few days of discharge.
- Hospital readmissions and post-discharge emergency room visits will be reduced.
- Adult day services will be assessed as a core component in Care Transitions.
