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.
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)
- Kidney failure
- Dementia or Alzheimer’s disease
- Parkinson’s disease
*Note: These are only some of the conditions that people may have and benefit from by being in the Home
If your are a UPMC Health Plan member, you may also have the following services depending on your condition:
- UPMC Visiting Nurses Care 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
- 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.
- 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
- 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