The Care Transition (CT) program is a free program for TRICARE-eligible beneficiaries recently discharged from an inpatient hospital admission. This program is designed to address the rate of avoidable hospital readmissions for chronic conditions such as:
- congestive heart failure,
- chronic obstructive pulmonary disease,
- diabetes, and
Under the supervision of Health Net Federal Services, LLC (HNFS), a registered nurse acts as the care manager and is assigned to work with a TRICARE beneficiary. When a beneficiary is discharged, a care manager will contact him or her by telephone to ensure the beneficiary and family caregivers understand discharge instructions; how and when to take prescribed medications; dates and times for follow-up appointments with the primary health care provider or specialist; and whom to contact if they are having problems. Additionally, the care manager will instruct the patient on the use of a personal health record to facilitate communication and help with continuity of care across providers and settings. The program includes follow-up calls from the care manager to help the beneficiary stay well and ensure a smooth transition from hospital to home.
Through the CT Program, beneficiaries will learn self-management skills they can put into practice to help better manage their health condition.
Beneficiaries recently discharged from an inpatient hospital admission who would like to speak with a nurse from the CT program can contact the Case/Care Management Department at 1-844-52-HELPU (43578) for assistance.