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The Care Transitions Program       


    MEOC has five (5) care transition coaches trained in the Care Transitions Intervention (CTI) developed at the University of Colorado under the leadership of Dr. Eric Coleman.  During a 4-week program, patients with complex care needs to receive specific tools, are supported by a care transitions coach, and learn self-management skills to ensure their needs are met during the transition from hospital to home.  Key findings of this model are that patients who received this program were significantly less likely to be re-admitted and more likely to achieve self-identified personal goals around sympton management and functional recovery.  MEOC is currently working with persons discharged from Norton Community Hospital, Indian Path Medical Center, Mountain View Regional Medical Center, Lonesome Pine Hospital and Holston Valley Medical Center.  MEOC is also a Money Follows the Person transition coordinator and can assist individuals living in nursing facilities to transition back to the community with the long-term supports they need.                                                                                                                                                                                                                                                                                                                                                         

    For more information, contact Judy Miller at jmiller@meoc.org