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Care Transitions
 
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Additional information about services and support to help people remain at home can be found on our In-Home Assistance page.  

Nearly one in five or approximately 2.6 million older adults are readmitted to the hospital within 30 days, at a cost of over $26 billion every year.  A high percentage of these readmissions are avoidable. The Prince William Area Care Transitions program is designed to help reduce avoidable readmissions by empowering individuals to manage their own healthcare. 
A Care Transitions Coach will work to transfer skills that will allow an individual to recognize red flags, communicate effectively with their primary care physician, identify medication errors, and keep track of important medical information, with the goal of significantly reducing the likelihood of an unnecessary return to the hospital within 30 days.
 
Residents of Prince William County, City of Manassas and Manassas Park are eligible to participate in this program if they meet all of the following criteria:
  • Resident is a Medicare Beneficiary
  • Resident has had a diagnosis of one of the following: Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Acute Myocardial Infarction (AMI), Pneumonia
  • Resident has been or is being discharged to a home or Skilled Nursing Facility
 
Please note: If a resident has dementia, an active caregiver must be willing to participate in the process on their behalf.
 
For more information please contact our Care Transitions Coordinator, Nakia Speller at 703-792-6408 or Nspeller@pwcgov.org.