what does the care transitions program do?
Using the Coleman Model of Care Transitions©, the RN evaluates the patient’s current health status and establishes a plan for meeting the goals of The Four Pillars®.
Pillar No. 1
Medication Self-Management" The patient is knowledgeable about their medications and has a system in place to ensure they are taken correctly.
Pillar No. 2
Dynamic Patient-Centered Record: The patient understands and manages a Personal Health Record (PHR) to help manage health goals, appointments, questions for providers and medications.
Pillar No. 3
Follow-Up: The patient schedules and completes follow-up visits with Primary Care Providers and Specialists.
Pillar No. 4
Red Flags: The patient is knowledgeable about signs and symptoms that their condition is worsening, and understands what to do.
The patient navigates through the pillars via an individualized care plan that is designed by the Care Transition Program RN. The patient’s completion of the Care Transition Program is contingent upon their ability to self-manage their condition (or demonstrate family management).