Transitional Care

Transitioning from hospital to home is a vulnerable time, often overwhelming and confusing. The role of the Transitions Health Coach is to assist with follow through and understanding of discharge instructions, empower the member to create personal health goals, review medications and identify areas of concern or discrepancy, and encourage collaboration between the member and Primary Care Physicians.

Direction Home partners with our area Health Plans to provide the Care Transitions intervention to members across Ohio, bridging the gap between patients and providers by focusing on the transition from hospital to home. The goal of the Program is two-fold:

  • To improve patient care and compliance during a hospital-to-home transition
  • To prevent potentially avoidable hospital readmissions

The Direction Home Transitional Care Program Has Proven Success

Direction Home has a long history of providing Care Transitions services. From 2012-2017, Direction Home was a CMS awardee of the Community Based Care Transitions Program, coaching over 27,000+ patients, resulting in 25.4% fewer hospital readmissions when compared with relative populations. The program helped reduce 30-day hospital readmissions from 19.6% in 2010 to 11.7% in 2016, saving area hospitals nearly $2 million in readmission costs.

Partner With Transitional Care

Direction Home Akron Canton is proud to currently offer Transitional Care Programs in partnership with Ohio health plans. You can become a Transitional Care partner today, improving patient outcomes and saving your Plan and facility money. Transitional Care can offer a variety of services, including but not limited to readmission risk assessments, bedside coaching, home safety checks, medication reconciliation and linkage from patient to case manager to physician.


For more information on offering the Transitional Care Program in your facility, contact Patrick Clevidence at 330-899-5301.

If you’re in need of Transitional Care services, call the Aging and Disability Resource Center at 877.770.5558.