Better Together: Transition to Wellness
Working with You
CJE SeniorLife in partnership with Presence Saint Francis Hospital
The Transitional Care Program is different from other medical services such as home health or physical therapy because the Transitional Care Nurse does not provide direct medical care. The Transitional Care Nurse works with you and your family to help you be better prepared to take charge of your health conditions and meet your own goals. This program focuses on you, your family and caregivers, and includes them as much as you would like.
For questions about the Community-Based Care Transitions Program, please contact: Sue Newman Director, Care Transitions Collaborative 773.508.1144 Sue.Newman@cje.net
Better Together: Transition to Wellness
Better Together: Transition to Wellness
CJE SeniorLife™ is a partner in serving our community, supported by the Jewish United Fund/ Jewish Federation of Metropolitan Chicago. 577.1.2014
Better Together: Transition to Wellness
What is Transition to Wellness?
This is a FREE service to help you:
It is a free, 30-day transitional care service from your hospital that helps you recover from your hospitalization and plan your care at home. This service has been developed to help you get home safely and smoothly, provide you and your family with education about your disease and medications, and aid in coordinating follow-up care with your health professionals.
s Understand and manage your medications. s Understand your disease and be aware of warning signs if it’s getting worse and what to do when they occur. s Understand and follow your discharge instructions. s Schedule follow-up physician appointments. s Maintain the good care you received in the hospital after you arrive home, or to your next care setting.
The day after you are discharged from the hospital, one of our specially-trained Transitional Care Nurses will call to set up a home visit. Within two days, our nurse will visit you one time at home and explain your discharge instructions, medications, and medical condition, then follow-up with three phone calls to again review with you any new medications, provide healthcare education, and prepare you for upcoming physician visits. This 30-day educational program is also available if you are moving first to short-term rehab or back to your long-term care facility. The Transitional Care Nurse works with your health care team to see that your discharge instructions from the hospital are in place at the time of your transfer.
You will receive the following services during the 30-day program: A Personal Health Record (PHR) designed to help you keep track of your medications and your medical appointments A home visit and three follow-up “coaching” calls from a Transitional Care Nurse during the transition from the hospital to your home, short-term rehab or your long-term care facility. If you are discharged from short-term rehab within your 30 days in the Program, our Transitional Care Nurse will make one additional visit to your home, and additional follow-up phone calls.
The goals of the Community-Based Care Transitions Program: s Improve your quality of living. s Improve communication between you and your healthcare providers. s Encourage your proactive participation in health care decision making. s In collaboration with your physicians, to discuss the disease process and how you can manage signs and symptoms of a worsening condition. s Prevent unnecessary emergency room visits and re-admissions to the hospital.
Better Together: Transition to Wellness
Working with You
CJE SeniorLife in partnership with Presence Saint Francis Hospital
The Transitional Care Program is different from other medical services such as home health or physical therapy because the Transitional Care Nurse does not provide direct medical care. The Transitional Care Nurse works with you and your family to help you be better prepared to take charge of your health conditions and meet your own goals. This program focuses on you, your family and caregivers, and includes them as much as you would like.
For questions about the Community-Based Care Transitions Program, please contact: Sue Newman Director, Care Transitions Collaborative 773.508.1144 Sue.Newman@cje.net
Better Together: Transition to Wellness
Better Together: Transition to Wellness
CJE SeniorLife™ is a partner in serving our community, supported by the Jewish United Fund/ Jewish Federation of Metropolitan Chicago. 577.1.2014