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  • Care Transitions Program at Avera

Published on January 10, 2013

Care Transitions Program at Avera

Avera means “to be well,” and Avera’s Care Transitions program is just one way Avera is working to help you stay healthier.

If you have been diagnosed with chronic heart failure, chronic obstructive pulmonary disease (COPD) or pneumonia and experience a stay at one of Avera’s 29 hospitals in the five-state region, you have the opportunity to enroll in the free program. As part of the program, patients receive educational materials and other tools to help you understand your medications and disease process, keep upcoming provider appointments and recognize potential symptoms.

Each patient also is assigned a transitional care coordinator, who visits the patient at home within 24 to 48 hours of discharge to review medications, answer questions and ensure that a follow-up provider appointment is scheduled. You gain the opportunity to work with your transitional care coordinator to create follow-up schedules, which include at least four telephone consultations during the first 30 days.

Care Transitions is an extension of the services provided during the patient’s hospital stay, and there is no additional charge for these services. The main goals of the Care Transitions program are to:

  • Help the people we serve to stay healthy and to be able to be active members of their communities
  • Ensure continuity of care as patients transition from hospital to home
  • Keep our patients out of the hospital if possible
  • Provide the highest quality care to every patient, every time