Patients who have been diagnosed with a chronic illness, progressive illness or end stage disease may benefit from “Transitions” care. Our program is specially designed to benefit those dealing with upcoming obstacles centered on personal health issues that will result in an upcoming lifestyle change, whether short or long-term.
Who Qualifies: You can make a referral for individuals specifically dealing with, but not limited to;
- Chronic Disease Management/Education
- Upcoming Surgery
- Patients who have been diagnosed with a progressive illness
- Metastatic disease with active treatment, curative or palliative
- Prognosis greater than 6 months
- End Stage Diseases (including heart, lung, liver, kidney, etc.)
This program is organized by Upper Peninsula Home Health, Hospice and Private Duty in collaboration with community organizations from across Marquette County. (See Partners) The program offers case management and volunteer support that is not medical in nature with the goal of identifying the needs of patients and their caregivers and coordinating assistance to ensure those needs are met with referrals and links to existing community resources.
The “Transitions” coordinator can help patients and families explore goals of care, discuss health care planning and assist with advance health care directives. Trained volunteers offer companionship, respite for caregivers and practical support like preparing a meal or running an errand. We coordinate referrals directly and ensure follow-through by following-up directly with program participants and patrons.
