Transitional Support

Helping Individuals Navigate Life's Transitions

Transitions between healthcare settings and the community can be complex. ESWA’s Transitional Support services help individuals access the resources, coordination, and guidance needed to move safely and successfully through important life changes. Whether someone is returning home after a hospital stay or exploring a transition from a nursing facility to the community, our team works to reduce barriers, connect people with supports, and promote independence.

Through the programs below, ESWA helps individuals and their families navigate transitions with confidence while accessing the services and resources needed for long-term success.

Supporting a Safe Return to the Community

Community Transition Liaison Program (CTLP)

The Community Transition Liaison Program (CTLP) helps nursing facility residents age 22 and older who are interested in transitioning back to the community. Available regardless of insurance type, the program provides personalized support to explore discharge options, identify barriers to community living, and develop a safe and successful transition plan.

ESWA’s CTLP team works closely with residents, family members, designated representatives, nursing facility staff, and community partners to coordinate services and connect individuals with state programs, housing resources, benefits, and community supports. The goal is to help individuals make informed decisions and access the services they need to live successfully in the community.

Whether someone is returning to a private residence, moving in with family, or transitioning to another community-based living arrangement, CTLP helps ensure the process is as smooth and successful as possible.

Online referrals can be made at:ESWA Intake Form

Supporting Recovery After a Hospital Visit

Transitions in Care

ESWA’s Transitions in Care program helps eligible participants make a successful transition from the hospital back to their home and community. Through personalized coaching and support, participants learn skills that can help them manage their health, understand discharge instructions, and reduce the likelihood of returning to the hospital.

A dedicated Transitions in Care Coach works one-on-one with participants during the critical weeks following discharge. Coaches help individuals review and understand discharge instructions, prepare for follow-up appointments, identify questions for healthcare providers, recognize warning signs that may require medical attention, and better manage ongoing health conditions. The program is designed to help participants feel informed, prepared, and confident as they recover at home.

Support may include an in-home visit and follow-up phone calls over a 30-day period. Coaches also help participants organize important health information, including medications, diagnoses, and questions for their healthcare team, while connecting them with community resources that may support their recovery and overall well-being.

The program aims to reduce avoidable emergency department visits and hospital re-admissions while supporting participants in reaching their recovery goals. Through education, guidance, and ongoing support, Transitions in Care helps individuals manage the challenges of returning home after hospitalization.

For more information, please visit: https://medicare.bluecrossma.com/member-resources/find-care/member-support-assistance-program