What is the Brooks Center for Care Transitions?
The Brooks Center for Care Transitions (BCCT) offers continuity of rehabilitation care after you are discharged from our hospital or skilled nursing facilities. During this 60-day program, you will have telephone and telehealth appointments to facilitate the continuation of your rehabilitation journey. The multidisciplinary BCCT staff includes medical providers (physician assistants, nurse practitioners), nursing and case management.
How does the program work?
Your first visit with a BCCT Program Guide will occur one to two days prior to your discharge at your bedside. Following discharge home, you will receive a telephone call within two business days to ensure your transition home was smooth. Next, a telehealth visit will occur within the first two weeks of discharge home. Subsequent telephone or telehealth calls will be scheduled based on your needs for 60 days following your discharge home. Additionally, your case manager is available to assist you throughout the program as needed.
What happens after discharge?
After you are discharged, you will receive continued guidance during your rehabilitation journey. We will focus on your rehabilitation needs including:
- Guiding therapy
- Transitioning from home health to outpatient services as needed
- Facilitating involvement in Community Programs
- Ensuring psychosocial aspects related to rehabilitation diagnosis are addressed
We will also assist in communicating with your primary care physician summarizing your telehealth visits. We will ensure you resume your primary care relationship for ongoing medical issues and that they are aware of your rehabilitation needs and progress. Lastly, we will help reinforce the importance of the primary care model for patients and caregivers.
How do I connect with BCCT?
You may contact the BCCT staff for questions regarding your rehabilitation following discharge by calling (904) 204-4100 or emailing BCCT@BrooksRehab.org. The BCCT will collaborate with your primary care provider (PCP) to optimize your health and recovery. Additionally, the BCCT staff is available to home health and outpatient therapy staff for continued coordination of services.