Transitional Care Programs

 

Two Transitional Care program options to fit our patients needs

Population Health At Home Transitional Care Program

Population Health at Home provides a level of assurance that the medical care and attention you received in the hospital does not stop but continues after you are discharged.

Our team of board-certified Advanced Practice Providers come to your home to review and manage your medical, social and behavioral needs. We take a patient-caregiver centered approach by including you and your caregiver in creating your post-discharge plan.

The team will update your primary care provider on your status and plan of care following the initial visit and continue to communicate and collaborate as needed. Our in-home providers may manage your care for up to 30 days with the primary goal being a safe transition back to your primary care provider.


Our Advanced Practice Providers will work with you and your caregiver to:

• Review your discharge instructions and plan.
• Discuss your medications with you and make changes as needed.
• Review how you have been feeling since discharge and address any new or worsening symptoms.
• Perform a physical exam.
• Order any blood work or tests you may need after discharge.
• Stay in constant communication with your doctor/provider about your care and health.
• Work with you on how you can self-manage your condition to increase your independence and effective coping.
• Provide emotional counseling to you and your caregiver.
• Identify challenges that could interfere with your ability to best care for yourself and help find resources to assist you.
Am I eligible for an in-home Primary Care Provider?
You may be eligible for in-home provider services visits if you have:
• A chronic disease or illness that affects your health and daily activities.
• Difficulty attending office visits with your primary care provider due to the severity of your illness or health condition.

You do NOT have to be home bound to be eligible for in-home services.

For questions or more information, call us at 856.382.6686.

RN Transitional Care Program

Population Care Coordinators are Registered Nurses (RNs) who engage high-risk patients for wellness and chronic disease, helping to self-manage chronic conditions. The care team will contact you when you are from the hospital and focus on promoting your health through education as well as evaluation of clinical, social, and behavioral health needs and connecting you with community resources. We can assist with the following:
• Provide Transitional Care services by contacting you each week for four weeks after your discharge from the hospital.
• Discuss preventive screenings and their importance.
• Provide education on chronic diseases, such as diabetes, asthma, heart failure, chronic obstructive pulmonary disease (COPD), valvular procedures/surgery, and coronary artery bypass graft (CABG).
• Review medication lists with patients and your caregivers and provide education where needed.
• Connect you with community resources.
• Help you adhere to your plan of care.
• Facilitate patient-centered goal setting and healthy self-management skills.
• Create a patient-centered care plan and re-evaluate your progress at set intervals.
• Manage patient care needs for four weeks or more, as needed or requested.

If you are newly discharged from a hospital or rehabilitation center, contact your Cooper provider’s office to request participation in the RN Transitional Care Program.

RN Transitional Care Program

Population Care Coordinators are registered nurses who engage high-risk patients for wellness and chronic disease helping you self-manage your chronic conditions. The care team focuses on promoting the patient’s health through education, evaluation of clinical, social, and behavioral health needs and connecting patients with community resources.

We can help:

  • Contact patients at discharge; identify and address clinical, social, educational, and behavioral health care needs.
  • Provide transitional care services by contacting you after your discharge from the hospital for four weeks.
  • Discuss preventive screenings and their importance.
  • Provide education on your chronic diseases such as diabetes, asthma, heart failure, chronic obstructive pulmonary disease (COPD), valvular procedures/surgery, and coronary artery bypass graft (CABG).
  • Review medication lists with patients/caregivers and provide education where needed.
  • Connect patients with community resources.
  • Help you adhere to your plan of care
  • Facilitate patient-centered goal-setting and healthy self-management skills.
  • Use motivational interviewing or behavior modification techniques to facilitate behavior change.
  • Create a patient-centered care plan and re-evaluate patient progress at set intervals.
  • Manage patient care needs for up four weeks or more as needed/requested.

What We Offer

Our Population Health Care Coordinators offer innovative care coordination services for our primary care offices and specialists to support the management of our patients in need through education and engagement.