Sussex County Employees Achieve Certified Care Transitions Coach Status
(Newton, NJ) The Sussex County Department of Human Services is proud to announce the successful training and certification of three of its employees as Care Transitions Coaches of the Coleman Institute's Care Transitions Intervention Program. The Care Transitions Intervention (CTI) was developed by Eric Coleman, MD, MPH, as an evidenced-based model of healthcare delivery that addresses the need for continuity of care among healthcare professionals and providers. The goal of the program is to empower chronically ill older adults in successfully transitioning from the acute-care hospital setting to home. Regina Hannapple, SW; Elizabeth Larsen, SW; and Sarah Balzano, RN, who are all Sussex County Department of Human Services, Transitional Care Program employees, were selected by the national organization to participate in the intensive two day training session in Richmond, VA. The program was designed for healthcare professionals to become Certified Transitions Coaches.
Stephen Gruchacz, Administrator for the Sussex County Department of Human Services stated, "The successful completion of this evidenced-based program raises the competency level of our transitional care program. With the assistance of these certified transitions coaches, senior citizens who have been discharged from the hospital and are high risk for readmissions will be engaged by our team to assist them in setting personal goals that can be used to prevent unnecessary readmissions. Through the development of a personal health record, daily contact with the patient and assistance in navigating the healthcare and human services network, this unique program saves money and improves the quality of life for older adults who reside in the County."
The role of the Care Transitions Coach is to assist older adults and their caregivers to become active participants in their own care. The Care Transitions Coach assists patients in developing new ways to empower themselves and to communicate more effectively with their healthcare providers. This effort also assists the patients in identifying common problems that may arise once discharged home from the hospital or rehabilitation facility and how to successfully manage those challenges and avoid unnecessary emergency room visits or hospitalizations. The Care Transitions Coach assists the patient in preparing a "PHR" or personal health record, make follow-up physician appointments, complete a
medication reconciliation and identify "red flags" or warning signs that may signal a change in their health status. Patients are referred through social workers and case managers during their hospital stay and are followed by the Sussex County Transitional Care program for a thirty day period. While on the program, patients are linked to an array of community services.
For more information on the Sussex County Department of Human Services, Transitional Care Program, please contact Sarah Balzano, RN, Transitional Care Coordinator, at 973-579-0559 ext 1247 or by email at firstname.lastname@example.org.
View a PowerPoint Presentation to obtain current information on the Sussex County Transitional Care Program.