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SMH Announces Care Transition Coach

Western Maine Health Vice President of Clinical Services, M. Patricia Cook, RN, MBA, EdD, announced recently that Stephens Memorial Hospital (SMH), working with the Maine Medical Center Physician-Hospital Organization (MMC PHO), is now utilizing the special skills of  Nurse Care Transition Coach Joan Frost to support older patients and their caregivers as they return home from SMH. 

A Nurse Care Transitions Coach helps patients and caregivers increase their self confidence about managing their chronic health condition, which could include Diabetes, COPD, CHF, as well as managing medications, and talking with their healthcare providers. The coach meets with the patient and caregiver in the hospital, makes a home visit and provides three follow-up phone calls during the four-week intervention. This program has been successful in more than 100 other hospitals.  The Care Transitions Model is based on the research of Eric Coleman, MD MPH at the University of Colorado as a means to help hospitalized patients at high risk for complications or re-hospitalization. It is a means to facilitate transition from hospital to home especially in view of shorter hospital stays.

Joan has both a bachelor's degree in Sociology and a Bachelor of Science in Nursing, she is also a Certified Diabetes Educator.  Prior to completing her care transition training and becoming a coach, Joan worked for Androscoggin Home Care and Hospice.

A long time resident of the Oxford Hills region, Joan lives in Paris with her husband, Chuck. 

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