Care transition coaches help get from hospital to home

Press release

Transitioning home after being discharged from the hospital can be challenging, especially for elderly individuals or those with complex medical conditions. Once a person has been discharged, it doesn’t mean that he or she is completely well or ready to recover at home alone.

Even people who have someone at home to help may need additional assistance to make the transition back to home successful. Northern Montana Hospital is partnering with other community hospitals across north-central Montana to help patients, along with their families or caregivers, have the support they need after leaving the hospital.

Funded by a three-year, $730,176 federal grant from the Department of Health and Human Services, the North Central Montana Center for Rural Health Care Transitions provides care transition coaches based in community hospitals throughout north-central Montana. There is also a care transition coach at Benefis Health System in Great Falls dedicated to working with rural patients across the region to help ease the transition following a discharge from Benefis back to their community.

During the first few days after a patient leaves the hospital, the patient is at a higher risk for problems to occur as they adjust to recovering at home. It is within this period of time that the care transition coach follows up with patients to ensure that their transition is going smoothly and addresses any questions or concerns from the patient and their caregiver.

The coach will also review symptoms and discuss the patient’s continued progress, review the patient’s medications, make sure they have access to needed medication and understand dosages and schedules, some of which may be new with the recent hospitalization.The coach can also help the patient arrange follow-up appointments with their doctor, meals, transportation, physical therapy, and other services important to their continued recovery at home. The care transition coach will continue to stay in touch with patients and their caregivers for as long as necessary and may even make a home visit if needed. There is no cost to the patient for utilizing this service.

People may be eligible if they live in rural north central Montana and:

• were recently hospitalized at Benefis or one of the other partner facilities,

• have a chronic condition,

• are on multiple medications, new medications or have had changes to existing medications, or

• have had more than one visit to the Emergency Room or hospital in the last 6 months.

Coaches at participating hospitals can be reached at:

• Big Sandy Medical Center, Big Sandy, 406-378-2188

• Liberty Medical Center, Chester, 406-759-6991

• Benefis Teton Medical Center, Choteau, 406-466-5763

• Pondera Medical Center, Conrad, 406-271-2217

• Northern Rockies Medical Center, Cut Bank, 406-873-3729

• Missouri River Medical Center, Fort Benton, 406-622-6115

• Benefis Health System, Great Falls, 406-899-4181

• Northern Montana Health Care, Havre, 406-262-1407

• Central Montana Medical Center, Lewistown, 406-535-2070

• Phillips County Hospital, Malta, 406-654-1100

• Marias Medical Center, Shelby, 406-434-3266

• Mountainview Medical Center, White Sulphur Springs, 406-547-3321

For more information regarding the North Central Montana Center for Rural Healthcare Transitions program, please contact Amy Sundstrom, Rural Healthcare Transitions Center Coordinator at 406-455-4862.