The Care Transitions Program – Innovating to meet the needs of patients

Over the past 5 years, Community Nurse Home Care has been offering follow-up support for our most fragile, recently discharged patients through our Care Transitions Program. This program helps to ensure that patients are following their health management routines while enhancing their independence and reducing hospitalizations. Through this supportive service we reinforce education, clarify questions and can identify and intervene in any emerging health issue. What makes this program special is the personal connections between our Care Transitions Coordinator, Michelle Tavares, and the program participants. For some, this interaction with Michelle is the only contact they have.

It has become clear there are many patients and individuals in our community that have ongoing complex medical issues and suffer with social isolation. It is part of Community Nurse’s mission to explore and intervene on these social determinants of health. 

Recognizing that our team is uniquely positioned to help these individuals, our staff along with the newly formed Innovation & Evaluation Committee began studying social isolation and exploring some proven interventions. This made us aware that although our telephone support has been helpful, in-person interaction could be even more beneficial. Recently, our coordinator, Michelle, has made some in-person visits and we are in the process of developing an official friendly visitor program. Community Nurse remains committed to growing this outreach program and to engaging more individuals in our communities in need. 

Special thanks go to our donors and especially, the Richard and Anne J. Prouty Foundation and the Association for the Relief of Aged Women (ARAW) for funds that are critical to this program’s success and growth.