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Beebe's Transitional Care Program

Mark Foti benefited from the CAREs program, which was introduced to him by Holly Rader, APRN, FNP.
Mark Foti talks to Holly Rader, APRN, FNP, a member of the CAREs team.

CAREs is a transitional care program in which specialized medical professionals assist people with chronic illnesses in learning how to manage their medical conditions so that they can stay at home and be as healthy as they can be.

CAREs stands for:

  • Care coordination
  • Access
  • Referral to community-based resources
  • Empowerment of patients

CAREs nurses and the other medical professionals are very experienced, especially with helping people who have several different health issues. They are highly educated and know about chronic illnesses. They understand how you feel. They also know of the many organizations and people who can support you in your effort to enjoy your life.

Qualifications: If you have complex health and social service needs, in addition to frequent hospitalizations (two or more admissions in the past six months), you may qualify for enrollment in the CAREs Program.

People enter this program through referrals from physicians and other healthcare providers. For more information, contact Population Health at 302-645-3337.

Who benefits from CAREs?

  • People who have difficulty managing their chronic health problems, such as:
  • Heart failure
  • COPD
  • Diabetes
  • Crohn’s disease
  • People who have been hospitalized several times over the past year.
  • People who know that they would like to enjoy life again, if only they knew how.

What is the cost?

You don’t have to worry. The extra attention provided by the CAREs team is free of charge. Team members simply ask that you are engaged in the program and willing to work along with them.

Visit the CAREs Resource Center for a list of community organizations that can help you.