Patients who have been diagnosed with a progressive illness or end stage disease but are not yet ready for hospice care may benefit from Transitions care. Transitions is appropriate for patients with:
- Metastatic disease with active treatment, curative or palliative
- Prognosis greater than 6 months
- End Stage Diseases (including heart, lung, liver, kidney, etc.)
Transitions is a community service program offering case management and volunteer support that is not medical in nature. The goal of the program is to identify the needs of patients and their caregivers and offer assistance in fulfilling those needs with referrals and links to existing community resources.
The Transitions medical social worker can help patients and families explore goals of care, discuss health care planning and assist with advance health care directives. Trained volunteers offer companionship, respite for caregivers and practical support like preparing a meal or running an errand.