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Care Transitions

Care Transitions

Statistics show that 20 percent of hospitalized Medicare beneficiaries are readmitted to the hospital within 30 days. Senior Services is developing pilot programs with local hospitals to reduce preventable hospital readmissions for older adults. Senior Services staff are certified in The Care Transition Intervention™ model, an evidence based program developed by Dr. Eric Coleman. Staff members act as Care Transition coaches, empowering patients to better manage their chronic conditions and achieve personal health goals. Research has shown that The Care Transition Intervention™ is highly effective in resolving issues that may lead to re-hospitalization, such as confusion about the discharge plan, lack of understanding about the chronic condition, and failure to receive timely follow up care.

Check with your hospital care team to see if Senior Services Care Transitions Program is available for you or a loved one!

Senior Services of Southeastern Virginia (SSSEVA) is a proud partner of the Hampton Roads Care Transitions Program, a partnership between SSSEVA, Sentara Healthcare, Southampton Memorial Hospital and Hampton University's School of Pharmacy. It aims to improve the quality of care for patients over 60 as they transition from the hospital to home.

The partnership thanks our program supporters:


Cardinal Health logo

Sentara logo

 Sentara Foundation logo



Our Care Transitions Team are Healthcare Heroes!

 Healthcare Heroes

Click here to read about our 2017 award.



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