Care Transitions


MHA’s Care Transitions Program is designed to help clients and their caregivers manage care after hospitalization. Community Health Workers (CHWs) work one-on-one with clients to support them in their transition from hospital to home. This program offers resource coordination and teaches clients self-advocacy and is not a home nursing program. CHWs help clients understand their condition and discharge instructions, assist clients with self-management of their healthcare, and connect them with any resources they need to make their road to health a success. Here are some of the services a CHW can provide:
  • Assistance with medication adherence
  • Securing transportation
  • Scheduling follow-up appointments with primary care doctors or specialists
  • Accessing nutritious food
  • Finding specific medical equipment
  • Guidance on speaking with healthcare providers and what questions to ask
Our CHWs advocate for clients and help clients learn how to be advocates for their own care. As a part of the Care Transitions Program, clients receive individualized care and coordination services based on their own unique needs.
For more information on the Care Transitions Program, please contact us at (707) 412-3176 X 101, or use the Referral Form on the right-hand side of this page to send us an inquiry directly. For bi-lingual services or services in Spanish, please call (707) 412-3176 X 106.

Referral Form

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