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VNS Services

Care Transitions

A free service to help manage a patient’s move from the hospital to home.
The 10-county region was selected by the Centers for Medicare & Medicaid Services (CMS) to join its Community-based Care Transitions Program.

The Care Transitions Coach program is easy and is available at no cost to qualified participants. Coaches and support staff are available 24 hours a day, 365 days a year to help.  

Program Benefits

  • Provides the tools to help people better manage their healthcare.
  • Eases the transition from the hospital back to home, ensuring all of the patient’s needs are met.
  • Reduces hospital readmissions and emergency department visits.

The Care Transitions Coach will:

  • Provide a hospital visit, one home visit and follow-up phone calls
  • Assess needs and concerns during a patient’s hospital stay.
  • Assist patient in completing their discharge preparation checklist.
  • Review the patient's personal heath record (PHR) to improve communication and ensure consistency of care across all providers.
  • Monitor patient status tomake sure their condition is not worsening.
  • Educate the patient regarding their medications
  • Help schedule and organize follow-up appointments with the patient’s physician.

Our goal is to empower people to take control of their health by providing the guidance, education and assistance needed to be an active player in managing their care.


All information in the Care Transitions Coach program is kept confidential and patient-specific informa­tion will never be disclosed without a patient’s written consent.

For more information on the Care Transitions Coach program, call 1.855.204.0888.