Transitions

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 client 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 by the next business day.

“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.”

- Bethany Benefield, Transitions Coordinator

Our Transitions program also includes team members Molly, Hollie, and Pam who support our neighbors across Central Oregon.

Find Additional Information & Resources here.

Transitions FAQs

When is the right time for Transitions?

If you have had a lot of recent health changes and current support no longer seems adequate, this may be a perfect time to reach out to our team. Our Coordinators are happy to meet with anyone who has questions about community resources. We can determine if someone seems appropriate for ongoing Transitions support.

Who is eligible for Transitions?

Anyone in the Central Oregon region who is medically fragile and living with a limited prognosis of roughly two years or less.

What type of support can I expect with Transitions?

A referral to Transitions typically results in a home visit to address any initial resource needs and evaluate the need for ongoing Transitions support. Patients and Coordinators will create an understanding as to the frequency of their check-ins. Most Transitions clients receive monthly phone calls to determine if there are any new needs or changes, and additional home visits can be scheduled as needed.

What isn’t included in Transitions?

Transitions Coordinators and Volunteers are not able to provide any hands-on physical care. We do not provide respite or caregiving and are not a substitution for seeking appropriate medical attention. Transitions is a non-medical, resource-based program.

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.