The Partners In Care Transitions Program Offers an Extra Layer of Support
Transitions is a no-cost, non-clinical case management program for medically fragile individuals with a limited prognosis, including those who may not qualify for home health or Hospice. Transitions Coordinators work with each patient to help identify questions, concerns, and areas of need for a personalized plan. We help clarify the different community resources available, which services are covered by insurance, identify out-of-pocket expenses, and help explore alternative funding options. Coordinators can also provide education about and facilitate referrals to home health, hospice, and palliative care.
Transitions is offered to individuals in any care setting, such as private homes, assisted living and memory care facilities, adult foster homes, rehab facilities, as well as the hospital.
It’s common for Transitions Coordinators to work with clients over several months or even years. While we aim to be an excellent point of contact for any resource needs, we also appreciate the opportunity to develop relationships with our clients and their loved ones. We are available at any time to address needs as they arise, but also offer friendly check-ins either over the phone or in person. In some instances, we also offer friendly volunteer visits, in addition to ongoing Transitions case management.
Anyone can refer to the Transitions program, from the patient themselves to medical providers, community members, and family members. For more information about the Transitions program or to make a referral, call the Transitions team Monday – Friday, 8 am to 5 pm at (541) 322-1289 or our main number outside those hours at (541) 382-5882; a Transitions team member will call you back.
“My favorite thing about being a Transitions Coordinator is the relationships that I get to build with my clients. I get to meet people often at a vulnerable time in their lives; we sit down together and talk about their experiences, their struggles, and what is important to them. My goal is to come alongside my clients and their families, help clarify goals, and navigate the different support options that make sense for their unique situation.”
When is the right time for Transitions?
Who is eligible for Transitions?
What type of support can I expect with Transitions?
What isn’t included in Transitions?
How is Transitions paid for?
Partners In Care is a nonprofit organization and our mission is to serve medically fragile individuals in the Central Oregon community. Transitions support is offered at no-cost to our clients because of the ongoing mission of Partners In Care.