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Hospital Transition & Patient Navigation

Care Transition Intervention Program

 In collaboration with Sierra Nevada memorial Hospital and as a service of the Aging & Disability Resource Connection of Nevada County, the Care Transitions Intervention (CTI)® program is designed to  prevent hospital readmission by supporting individuals and their  families to be more knowledgeable in self-managing their care and to feel confident that they can successfully respond to common problems that arise after discharge from the hospital. The CTI program utilizes coaching and skill transfer techniques.

  1. Medication Self-Management
  2. Follow up with Primary Care Doctor or Specialty Care
  3. Knowledge of Red Flags
  4. Develop a Personal Health Record (PHR)

The Transitions Coach meets with the   consumer in the hospital and then makes a home visit and approximately three follow up phone calls depending on the    consumer and the support they   request.

The Coach supports individuals with complex health conditions, disabilities, & older adults through direct services & connection to needed health care & safety net    service & programs in the community.


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Transition Home from Nursing Home

Are you or someone you know exiting a nursing home, skilled nusring facility, mental health hospital or other institutional setting.  Would you like support to return to community living?  FREED provides comprehensive person-centered planning, short-term service coordination, and in some cases can provide needed equipment, supplies and funds.

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Youth Transition

FREED has programs and services to support young adults with disabilities work towards their goals as they move into adulthood.  FREED can support the development of goals and plans, connection to resources, and ongoing support to navigate this important transition from a school-based system of services to independent living, employment or secondary education.