Care Transitions

Our Care Transitions Programs help older and disabled adults transition from the hospital or rehab setting to home. Our programs are designed to improve the care of newly discharged Medicare beneficiaries at high risk for readmission to the hospital.

Tri-Valley has certified Coleman Coaches™ on staff to provide care transitions coaching to eligible disabled and older adults. The Coleman Care Transitions Intervention Program™ is an evidence-based program that has been proven to reduce preventable re-hospitalizations with its Care Transitions Intervention™ Model.

Our Transition Coaches provide a patient centered approach to teach self-management skills, and use specific tools to help ensure that transition needs are addressed in a timely and appropriate manner.   Transition Coaches serve as a knowledgeable resource for patients as they move across different health care settings. Patients and their caregivers are coached to take a more active role during these care transitions.

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