Pen Bay’s Care Transitions Coaches work to keep patients home

By Donna Dugal and Patricia LaVallee | Jan 12, 2014
Donna Dugal, RN, BSN, left, and Patricia "Trisha" LaVallee, RN, BSN, are Care Transitions coaches.

Do you receive Medicare benefits? Are you are an adult patient with a chronic or progressive disease? If you have have recently been discharged from Pen Bay Medical Center and have other specific clinical risk factors, you may eligible to receive assistance through the Care Transitions Program. This 4-week program offers patients with complex care needs to work with a Transitions Coach and learn self-management skills to ensure their needs are met during the transition from hospital to home. Transitions Coaches make one home visit as soon as possible after the patient returns home and then follow up phone call for the next three week or as requested by the patient. This is part of their hospital stay and carries no additional cost to the patient.

The Care Transitions Program focuses on four areas:

  • Assistance with medication management
  • Learning how to use communication tools such as a Personal Health Record
  • Understanding the importance of seeing providers in a timely manner
  • Knowledge of “red flags”

Coaches also provide community resources as needed with the help of community partners such as the regional Area Agencies.

Donna Dugal, RN, BSN, Care Transitions nurse manager and coach, works with the physician practices of Pen Bay Internal Medicine, Pen Bay Family Medicine and Coastal Maine Internal Medicine to assist high risk patients with their health issues. Assistance includes home visits with patients to assess barriers, providing health education to promote improved health outcomes using motivational interviewing techniques and assisting doctors and providers with making community referrals.

“I became a nurse because I wanted to work more closely with patients. It has been a wonderful opportunity to connect and work with people,” said Dugal who has worked in the healthcare field for more than 20 years.

Patricia (Trisha) LaVallee, RN, BSN, Care Transitions coach, helps support adult patients and their caregivers as they return home from the hospital. She works directly with patients to prior to their discharge from the hospital, helps setup their Personal Health Record and encourages them to be an active participant in their interactions with providers.

“My love for the independent spirit of Maine people has given me great insight into how to live life well. I feel particularly drawn to those nearing the end of life. Helping to provide smooth transitions for those who have been acutely ill is also very rewarding. The volume of information a patient and their families receive on hospital discharge can be overwhelming even when it is clear and well taught. After many year of receiving discharge information from various sources, some more helpful than other, this position provided an opportunity to help make the process a bit smoother," LaVallee said.

For more information about Care Transitions program, contact Donna Dugal at dugald@mmc.org or 207-699-6139. Lavallee can be reached at lavalp@mmc.org or 615-8167. If you receive Medicare benefits, please ask your provider about this service.

Donna Dugal, RN, BSN and Patricia (Trisha) LaVallee, RN, BSN, are Care Transitions coaches at Pen Bay Healthcare.

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