Care Transitions

...The Next Step in Your Recovery After Leaving the Hospital

The Atlanta Regional Commission is collaborating with 6 Atlanta hospitals providing a community based intervention for traditional Medicare patients. The goal of this program is to enable older adults and their caregivers to move safely and smoothly from hospital to home, reducing avoidable hospital re-admissions.  

Care Transition Coaches work with patients in their home after hospital discharge, instilling confidence to support self-care, providing assistance in accessing important resources, and providing short term support services (home delivered meals, transportation, and care management) when necessary. 
     Participating Hospitals:

   In order to be eligible a person must: 
  • Be a patient at 1 of the 6 partner hospitals 
  • Have a high risk diagnosis 
  • Have traditional fee-for-services Medicare (Part A and B) 
Download the Care Transitions Info Card:

For more information, contact 404-463-3159

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