Transition Support Program

Mission

The primary goal of the Transition Support Program is to prevent rehospitalization, improve health and safety outcomes, and promote patient and family autonomy once the patient is discharged from Shepherd Center. The Transition Support Program is offered to referred clients free of charge and provides an average of eight weeks of follow-up.

Program Goals

  • Assess clients for early prevention of medical complications.
  • Reinforce knowledge and skills learned in hospital based rehabilitation programs.
  • Facilitate effective medication management.
  • Provide recommendations for home safety.
  • Assist in the identification of local community support services.

Clients entering the program will collaborate with a Transition Support case manager to achieve goals by:

  • Moving toward optimal health, safety and wellness management.
  • Following discharge plan and home care instructions to prevent rehospitalization.
  • Developing a client-centered treatment plan in the home.
  • Locating and utilizing appropriate community resources (financial, healthcare, wellness, etc).
  • Developing self-advocacy for medical, health and wellness needs.

CONTACT INFORMATION