Transitions Services & Supports Program

Yes, managing your health care can be overwhelming, but it doesn't have to be.

If you have Medicare and live with two or more chronic conditions, like arthritis, diabetes, depression or high blood pressure, chronic care management services can help connect the dots so you can spend more time doing what you love.

MAC, as an Area Agency on Aging, is addressing the social determinants of health through its Transition Services and Supports Program, working to reach people during the transition from one care setting to another, with person-centered hospital discharge planning as a key component.

MAC’s specialized Transitions project will target the reduction of health care costs through partnerships with area hospitals, accountable care organizations, primary care physicians and federally-qualified health care clinics.

Services may include:

  • Monthly management services
  • Personalized assistance from a dedicated health care professional who will work with you to create your care plan
  • Coordination of care between your pharmacy, specialists, testing centers, hospitals and more
  • Phone check-ins between visits to keep you on track
  • Expert assistance with setting and meeting your health goals

Person-Centered Hospital Discharge Planning

This program helps those who are at risk for long-term institutionalization or frequent hospitalization connect with services that will help them return to the community in a safe, independent and healthy manner.

A nurse from MAC will evaluate the person’s needs to identify programs and services that may benefit them or family members, and make recommendations.

The nurse will follow the client in the community following discharge to ensure a safe and healthy transition.

 

Eligibility

Frequent re-admissions to the hospital
Senior citizen or disabled adult
At-risk of long-term institutionalization
Wicomico County resident

For more information:
Joan Emerick, R.N.
410-742-0505, ext. 111
jme@macinc.org