Care Transitions

Care Transitions 2016-10-25T14:23:19+00:00

The staff at Natick Visiting Nurse Association and Distinguished Care Options believes in putting the needs of  patients and clients first, ensuring that they achieve the best possible outcomes and have the most satisfying experiences with the health care and non-medical services they receive from our agencies.

In today’s health care environment, it’s easy to get overwhelmed by all of the information available and choices that have to be made at every level of care. This is especially true when planning for one’s own hospitalization or helping a loved one plan for a discharge back to home from a hospital or rehab facility.

One thing is for certain: everyone would rather come home as soon as they can while knowing that they will receive the appropriate care when they do.

That’s where our Return To Home program comes in. Our Care Transitions Coordinators (CTCs) – RNs with nearly 60 years of experience between them – will act as personal health care guides to our patients and clients. They focus on getting to know the individuals and families they work with and providing them with options that make sense for their clinical and lifestyle goals—while taking into account their financial and health coverage options.

In the hospital or rehab facility, our CTCs meet with patients, clients and families to confirm individual needs and gather necessary information so that the plan developed works.

While patients remain in the facility, our CTCs will be in touch with their case manager, team of physicians and family caregivers to ensure that all relevant information is being communicated clearly, efficiently and effectively, keeping patients in charge of their own course of care.

Through their expertise in navigating the discharge process, the CTCs will ease the patient’s transition from facility to home and will serve as a trusted expert for the patient and family.

Additionally, our Care Transitions Coordinators may:

  • Conduct a home safety evaluation to ensure that the patient’s home is safe and identify potential safety risks before the return home to heal (if needed)
  •  Assess needs for adaptive or assistive equipment, including a telehealth monitor, and inform patient on how to obtain such equipment (if necessary)
  •  Closely monitor patient progress from hospital admission to discharge home
  •  Participate in discharge meetings
  •  Visit patient on the day of discharge to ensure that the patient understands the discharge instructions


Our Care Transitions Coordinators help patients and their families arrange for skilled services and private care in the home.