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Home Transitions Program

The Home Transitions Program is specifically designed to meet the needs of people who have had a recent hospital or skilled nursing home stay and are now returning to home. The program’s goal is to provide an extra layer of support and care for people who are dealing with certain chronic conditions and are at risk for re-hospitalization.

Who Can Benefit from the Program?
If you have recently been in the hospital or a skilled nursing facility, and if you have any of the following health conditions* you could benefit from the Home Transitions Program.
  • Congestive Heart Failure
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Diabetes
  • Kidney failure
  • Dementia or Alzheimer’s disease
  • Parkinson’s disease
  • Cancer
*Note: These are only some of the conditions that people may have and benefit from by being in the Home Transitions Program.

Your Home Transitions Team Includes:

  • UPMC Home Healthcare Team which may include a Registered Nurse, Physical, Occupational or Speech Therapist, Home Health Aide, Dietician, Wound Care Specialist, and Behavioral Health Nurse depending on your needs.

  • The social worker can help you and your family adjust to episodes of acute and chronic illness. The social worker can assist with a range of needs, including establishing goals of care and access to community resources.

  • A Transition Care Coordinator will work with your home care team, and your doctors to make sure that your care goes according to plan.
If your are a UPMC Health Plan member, you may also have the following services depending on your condition:
  • A Pharmacist may review your medications with your home care team and primary doctor

  • A Nurse Practitioner may be consulted to assist your home care team to treat the symptoms of your illness, to help control your pain, and discuss your goals of care
Your Home Transitions Team Will:
  • Develop a personalized treatment plan taking into account your health care goals
  • Communicate with you and your family about your health
  • Provide treatment for your pain and symptoms
  • Routinely examine you for early detection of changes in your condition
  • Provide clear communication about your illness and treatment choices
  • Ensure coordination of care between all of your health care providers
  • Connect you with community resources and services that can help support you and your family during your illness

To determine if the Home Transitions program is presently available in your service area, please call: