Health & Wellness - Emerson Hospital

Catherine Price, MD, an Emerson
hospitalist, reviews a discharge
summary with a patient.
care transitions program:
a pilot program due to expand
Emerson’s Care Transitions Program is, at this point,
a pilot project that is available to many residents
living in the hospital’s service area. The goal is to
expand the program and services to all patients and
families who will benefit from the added support
needed after a hospital stay.
For more information about the Care Transitions
Program or other care management
services at Emerson, please contact the
hospital’s care management department
at 978-287-3170.
After the hospital:
a recipe
care transitions program is a valuable tool
It’s a troubling situation, especially when it could have been prevented. It is the
phenomenon where individuals leave a hospital after receiving the appropriate care,
only to land back in the hospital days or weeks later. Why does it happen
“People with chronic conditions, such as heart failure or diabetes, can be hospitalized
a lot and need support in order to have a successful outcome,” explains Cheryl
DiPaolo, RN, director of care management. “Those conditions can be difficult to
manage once a person leaves the hospital setting.” The resulting, repeat hospitalizations
are expensive, as well as frustrating to patient, family and caregivers.
Emerson Hospital and Minuteman Senior Services have banded together with the
goal of preventing unnecessary repeat hospital stays. Using research, they have created
the Care Transitions Program, a free, 30-day initiative that is designed to give
patients precisely what they need to recover successfully at home, in a rehabilitation
facility or at a nursing home.
The transitions coach: a new role, and an essential one
Once a hospital patient is identified as being at risk for a repeat hospitalization, he or
she is invited to participate in the program. A Care Transitions Program coach then
visits the patient and describes the program components, which include reviewing
the patient’s medication regimen, making a follow-up appointment with the primary
care physician within a few days, discussing the “red flags” — symptoms that mean
6