Transition Back Home

Are you making the transition back home after a recent stay in the hospital, rehabilitation, or skilled nursing facility?

How will our Transition to Home Program help you (following an inpatient stay)?

• You will receive telephonic coaching from a Nurse Care Manager to discuss your discharge paperwork at your convenience
• We will offer support and education related to facility admission details and disease processes
• Specific conditions include surgeries, cardiac, respiratory, gastrointestinal, neurological, and other medical diagnoses
• Education about use and side effects of medication
• Assistance with questions to ask the doctor and making sure all follow up appointments are scheduled
• Coordination with the treatment team, including physicians and visiting nurse clinicians, on your specific care plan
• Providing assistance with available community resources and navigating benefits
• Transition to outpatient facilities as needed
• We will discuss mutually established health care goals for you to achieve
• Call one of our Behavioral Health Care Managers to help address behavioral health issues that may be impacting your physical health during business hours at 800.208.9565
• We will assist in having conversations with you that facilitate life planning, setting goals, and communicating these goals to your families, significant others and providers.
• We can help with long-term planning and implementing important documents associated with your health care decisions such as health care proxies.

What do your benefits cover (Medications? Durable medical equipment? Lab work? Inpatient/outpatient care?)

If you have questions about your benefit coverage, please check your Evidence of Coverage Document (EOC) on mytuftshealthplan.com or call our member services number on the back of your ID Card.

Have a medical concern and not sure what to do?

You have options to access the care you need when you need it. Review your discharge paperwork with:

• Your Primary Care Provider or Specialist
• One of our compassionate and experienced Nurse Care Managers (specializing in transition to home support) during business hours at 888.766.9818 ext. 53532
• Call one of our Behavioral Health Care Managers to help address behavioral health issues that may be impacting your physical health during business hours at 800.208.9565
• A U.S. board certified doctor or therapist by web, phone, or mobile app – 24/7/365 by registering for telehealth, powered by Teladoc® at teladoc.com/tuftshealthplan¹

Hospital discharge support videos

Register or Login to mytuftshealthplan.com to access relevant hospital discharge support videos including:

• Your Hospital Stay: Going Home
• Hospital Discharge Planning
• Getting Help When You Leave the Hospital

1. Please check your Evidence of Coverage (EOC) on mytuftshealthplan.com for coverage since your employer may be a self-insured Commercial group who needs to opt-in to this program. Telehealth is not available for members with Tufts Health Direct, Tufts Health RITogether, Tufts Health Together, Tufts Health Unify, or Medicare plans.