Partners’ trained health coaches and social workers work closely with individuals in urgent need of coaching and/or care coordination to connect them with services that will enable them to live well at home.
People served by our Care Transitions Choices program typically have just been released from the hospital or a nursing home, which is a time of maximum risk for medication errors, falls or worsening health. For our HomeMeds Plus program, referrals are typically made for complex patients already in the home.
A primary outcome for these programs is a substantial (34% to 66%) reduction in hospital readmission rates, with an implicit improvement in health indicators.
Typically Partners’ services for these programs take place under contract with health plans and hospital systems who wish to improve their patient/members recovery and care experience.
Short-Term Care Management Services are provided through members of the Partners at Home Network, who implement Partners’ evidence-based programs Care Transition Choices and HomeMeds Plus.
Learn more by clicking on the links below: