Help After a Hospital Stay

June 08, 2017
Transition Of Care Program

It can be good to get back home after a hospital stay, but managing your care in those first days and weeks can be challenging. To help support successful recoveries and prevent readmission to the hospital, a Transition of Care program is in place for Medicare* patients who have received inpatient care through The Valley Health System for:

  • Acute myocardial infarction (AMI)
  • COPD
  • Congestive heart failure
  • Elective hip and knee replacements
  • Pneumonia

The 30-day program is offered through a collaboration with Evolution Health, which provides post-acute services, including home visits and 24/7 phone support. Services are provided by nurse practitioners and physician assistants, and may include prescribing medication, addressing medical concerns and confirming appointments. The Transition of Care program does not take the place of home health, but is a way for patients to get extra support when they may need it most, says Melanie Sims, RN, COS-C, Executive Director of Evolution Health.

Is It Covered By Insurance?

If patients choose to enroll in the Transition of Care program, Medicare* reimburses 80 percent, and the other 20 percent is billed to patients’ secondary insurance; if patients do not have secondary insurance, they are responsible for the 20 percent, Sims explains.

How Will You Be Contacted?

Patients who are candidates for this program are contacted by phone by a nurse, usually within the first hours of arriving home from the hospital. This is a good time to ask questions and discuss what kind of support you may need. If you decide to enroll in the program, a visit to your home by a nurse practitioner or physician assistant will be arranged, usually within 48 hours.

* Please note: This program is for Medicare (not Medicare HMO) patients. If you have questions about your insurance coverage, please contact your insurance provider.

For more information about the Transition of Care program, call