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Local Hospitals Partnering to Help Bridge the Gap from Hospital to Home

Havre, Montana Transitioning from hospital to home after discharge can be challenging, especially for those who are older or have complex medial conditions. Just because a person has been discharged doesn’t mean he or she is completely well or ready to go it alone. Even those who have someone to help them once they get home sometimes need extra help to make the transition. That’s why Northern Montana Hospital is partnering with other community hospitals across north central Montana to make sure patients along with their families or caregivers have support and follow-up if needed once they leave the hospital.

Funded by a three-year, $730,176 federal grant from the Department of Health and Human Services, the North Central Montana Center for Rural Health Care Transitions provides for care transition coaches based in community hospitals in Chester, Malta, Lewistown, Havre, Big Sandy, Fort Benton, Conrad, Shelby, Cut Bank, White Sulphur Springs, and Choteau. There is also a care transition coach at Benefis in Great Falls who is dedicated to working with rural patients across the region to help bridge gaps when they are discharged from Benefis back to their communities.

Those first few days after a patient leaves the hospital and is adjusting to recovering at home can be a critical time for many people and a time when there is more risk for problems to occur. The care transition coach follows up with patients to ensure their transition home is going smoothly. A post-discharge phone call is made within a few days to identify concerns or questions the patient and their caregiver may have as well as anything the patient needs to support their recovery at home. They also review symptoms and discuss the patient’s continued progress. The coach reviews the patient’s medications and make sure that he/she has access to needed meds as well as understands dosages and schedules, some of which may be new with due to the recent hospitalization. If needed, the coach also helps with patient with follow-up appointments with their doctor or with arrangements such as meals, transportation, physical therapy, and other services important to their continued recovery at home. The care transition coach will continue to stay in touch with patients and their caregivers for as long as necessary and may even make a home visit if needed. There is no cost the patient.

If you live in rural north central Montana and were recently hospitalized, have a chronic condition, are on multiple medications, new medications or have had changes to existing medications, have had more than one visit to the Emergency Room or hospital in the last 6 months, you may benefit from having a care transition coach. Coaches at participating hospitals can be reached as follows:

Sandy Medical Center, Big Sandy – 378-2188

Liberty Medical Center, Chester – 759-5181

Benefis Teton Medical Center, Choteau – 466-5763

Pondera Medical Center, Conrad = 271-2217

Northern Rockies Medical Center, Cut Bank – 391-2255

Missouri River Medical Center, Fort Benton – 622-3331

Benefis health System, Great Falls – 899-4181

Northern Montana Health Care, Havre – 265-2211

Central Montana Medical Center, Lewistown – 535-6255

Phillips County Hospital, Malta – 654-1100

Marias Medical Center, Shelby – 434-3200

Mountainview Medical Center, White Sulphur Springs – 547-3323

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