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Transition-to-Home Program

Calvert Memorial Hospital created the Transitional-to-Home program to enhance care for chronically ill patients after they leave the hospital. The innovative community outreach program is designed to:

• Identify patients with chronic conditions (such as diabetes or hypertension)  who are at risk for readmission
• Provide them with additional support after they’re discharged
• Connect them with the resources they need to stay healthy
• Reduce preventable hospital readmissions

Patients may be invited to participate in this special program to help them after they are discharged from Calvert Memorial Hospital. This program is designed to improve the continuity of care for patients with chronic health conditions, such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes, as they transition between these different health settings.  Our goal is to ensure that the transfer of care between Calvert Memorial Hospital and these other settings goes smoothly.

This is a FREE service to help you or your loved one recover while helping you:

  • Understand and manage your medications better
  • Prevent unplanned re-admissions to the hospital through a better understanding of your diagnosis
  • Make a plan for necessary follow-up with your physicians or other home care services after discharge

Patients participating in this program may receive the following services during the six-week program:

  • A home visit to assess and assist with the management of their medications and their health information as well as help the patient prepare for their follow-up visit with their health care provider
  • Follow-up phone calls from the Transition-To-Home team, who will provide support, education, and any specialized educational referrals during the transition from the healthcare facility to home.

This program provides coordination and education to supplement other skilled home services you may be eligible for.

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