Our Transition Coaches help bring a wide range of community resources to our patients and bridge that gap in health care.
Our Transition Coaches are here to help with:
LIVING ENVIRONMENT: Where do they live now? How are conditions at home, how they feel about living here? Is this sustainable long term?
FUNCTIONING: (Physically and cognitively) what can they do for themselves? What are they struggling with?
SUPPORTS: Family, friends, caregivers, community programs/groups, income, transportation, tools that are helpful.
COGNITIVE: What do we see in the chart and what do we see? What is it compared to their baseline? How is it impacting their goals?
EMOTIONAL: Current coping, any mental health diagnoses that are relevant, how is it impacting their healing right now?