The [email protected] Care Transitions Program is providing COVID-19 to patients ages 18-59 with a disability or ages 60+ with comprehensive care transitioning services.
[email protected] will focus, for a period of at least 30 days and up to 90 days based on need, on providing timely access to in-home social support, psychosocial support services and health care coordination services. Examples of services provided include:
- Home-delivered meals for 30 days
- Weekly Telephone reassurance calls
- Grocery shopping assistance
- Prescription pick-up or delivery assistance
- Arrangement of follow up visits with PCPs and specialists
- Reinforcement of discharge plan instructions
- Coordination with client’s health plan or insurer for timely receipt of covered services
- Access to other community social programs such as rental assistance, utility assistance, application for SNAP, ALTCS, SAIL etc.
Eligibility is limited to older adults aged 60 and older and adults aged 18-59 with disabilities who:
- Tested positive for COVID-19 and are experiencing symptoms OR
- Were discharged with a COVID-19 diagnosis from a hospital or Skilled Nursing Facility OR
- Are at risk of getting COVID-19 due to having chronic conditions and prior exposure to another family member with COVID-19. *New eligibility criteria*
Referrals should be made within 14 business days of a COVID-19 positive test result, a COVID-19 diagnosis or discharge from a hospital or skilled nursing/post-acute due to COVID-19 and/or exposure to someone with COVID-19.
The Area Agency on Aging invites community agencies, hospitals, skilled nursing facilities, health plans and case managers to refer eligible patients to the [email protected] Care Transitions Program for COVID-19 eligible individuals as described above. COVID-19 affected clients may also self-refer.
To refer patients, call the [email protected] Program at (602) 883- 3527. For additional program information, contact Christine Liberato, VP Program Development at (602) 280-1050 or email her at [email protected].