Care Transition Support
The Care Transition Support program offers eligible participants person centered planning and short term case management services after being discharged from a hospital or nursing home, to ensure the participants have support in meeting their discharge goals.
What is Care Transition Support?
Since 2010, our organization, has worked in partnership with Cheshire Medical Center (CMC) Dartmouth Hitchcock Keene and the NH Department of Health and Human Services via our Monadnock ServiceLink program to provided Care Transition Support services. Currently, ServiceLink options counseling staff are on the site at CMC every Monday—Thursday. They receive referrals from hospital discharge planners as well as from NH DHHS staff. A ServiceLink options counselor meets individuals at the hospital, developers a person-centered action plan with the individual and follows up with them at home until they have successfully connected to needed medical or non-medical services. ServiceLink staff educate and empower patients to connect with their primary care team as well as with non-medical entities important to successful community based living.
Who is Eligible?
People being discharged from Cheshire Medical Center Dartmouth Hitchcock-Keene and local nursing facilities.
We also work with NH Hospital and other hospitals in the northern New England.
What Happens Next?
Once referred by a hospital discharge planner or social worker, an NHCC/ServiceLink Options Counselor contacts the referred person as soon as possible, either while they are at the hospital or at their home soon after discharge, to facilitate person centered planning, application support, assistance in connecting to services, and follow up. If you have questions about a referral made to NH Care Collaborative or to a ServiceLink office please call us at 603-357-1922 or email [email protected].
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