Care Transitions to the Community and Home (CATCH) is a hospital-to-home transitions program for Medicare patients discharged to home with or without Home Health services.
Medicare Patients who qualify are assigned a CATCH “Transitions Coach” (RN) who will take primary responsibility for managing patient care post- hospital discharge.
Medicare Patients who participate receive the following interventions:
- F/u phone call within 72 hrs. from an RN who will determine if the patient has successfully filled all prescriptions and is taking medications as prescribed
- Assistance with connecting to all f/u medical care and community resources
- Disease specific education with emphasis on “Red Flags” to prevent readmissions
- RN home visit for those not receiving skilled HH services.
- Additional Support Services (meals, transportation/and or in-home companion services) .
- Transitional Care follow-up for 30 days post d/c based on motivational interviewing techniques centered on patient goals to improve chronic disease self-management.
- Medicare Part A and Part B insurance
- Discharged to home, regardless of whether patient has home health
- Residence in one of the 11-county region: Durham, Franklin, Granville, Person, Vance, Warren, Alamance, Orange, Chatham, Johnston, and Wake
Must have at least one of the five target conditions:
- Heart failure (or history of heart failure)
- Acute myocardial infarction
- Chronic obstructive pulmonary disease
- Primary diagnosis of a psychological condition
- Dually eligible for Medicare and Medicaid
- Enrolled in Medicare Advantage Plan
- Discharged to skilled nursing or long-term care facility
- Enrolled in a hospice program