SMH Announces Care Transition
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
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.
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.
time resident of the Oxford Hills region, Joan lives in
Paris with her husband, Chuck.