Montrose Regional Health – Care Transitions Program
Montrose Regional Health recognized that patients with complex needs have a high risk for readmissions and require enhanced care and connections to providers and community resources during the discharge process and beyond. To meet this need, Montrose Regional Health implemented the Care Transitions Program, which provides a hand-off period between inpatient care and the community setting to ensure continuity of care and safe patient transitions.
Key elements of the program include:
- Regular contact (both in-person and by phone) with the patient post discharge
- Education and follow-up on discharge instructions and additional treatments and testing needed
- Medication management services
- Referrals to community providers
- Attending appointments with patients (especially the first appointment post hospital discharge)
- Addressing social needs/barriers to care and connecting patients to needed resources
Successes include the following:
- Secured housing for two previously unhoused patients
- Strengthened partnerships with community providers
- Opened program to community provider/clinic referrals
- Assisted 200 patients since launching the program in November 2024
To learn more about this program, please contact Sally O’Connor, director of care management, at [email protected].