Windsor Transitions: CareFits.
Transitional Care is defined as a continuous process of helping patients transition between one setting of care to another as they move along the continuum of care.
At Windsor, we have designed a program to assist hospital systems and post-acute healthcare entities help patients navigate the healthcare system through education, training and goal setting.
The goal is to help patients achieve independence and thrive in the appropriate level of care setting.
Our Care that Fits program includes:
- Patient education materials specific to a diagnoses with 1:1 coaching
- Chronic disease management checklists to better manage care and identify early warning signs
- A Transition Coach that meets the patient prior to admission and follows through after discharge
- Helping patients understand and fully utilize community resources, enhanced care resources, insurance and benefits
- Understanding medications, medication checklist for proper dosing, and checklist for possible side effects.
- Root cause analysis: what led to the acute episode to better prevent further episodes
- An assessment of what is needed at home to be successful, including home visits, environ-mental safety, family and caregiver classes, follow-up care including exercise diet and wellness programs
- A personal coach A Personal Health Journal (PHR)
Transitional Healthcare coaches will help the patient become the driver of their healthcare. Windsor’s care team will be here to support the patient with their goals in a meaningful way and create a path to recovery. Windsor will guide the patient, always remembering they know better than anyone else.