Our Transitional Care Wellness Teams work in and out of hospital behavioral health departments to provide patients being discharged with intensive, time-limited transitional services designed to ensure their continuity of care, prevent readmissions, and improve their health outcomes.
After forming a peer-to-peer relationship in the hospital, our staff begin by transitioning people back to their homes, ensuring that the process is comfortable, supportive, and trauma-informed. We then help people understand and implement their discharge plans, maintain useful contact with their care teams and support systems, connect with behavioral health clinics and primary care doctors, and learn to manage their own medications. We’re also there to help people learn how to improve to their overall health and well-being, and support them as they work towards wellness-related goals of their own choosing.
“As a member of the Transition of Care team, I have been working with Michael. I met him when he was in the behavioral health unit and was in need of a lot of different types of services and supports and then, connection to those different resources in the community. It was new territory for Michael since he was unsure how to navigate. Since we act as ‘resource brokers,’ we can connect people to those types of resources in the community where they will be most helpful.” -Zachary Cohn, Peer Advocate