Harmony Rivest – Transition Coach – CAWM

Care Alliance of Western Massachusetts (CAWM) is a partnership of eight agencies working together to connect consumers with long-term services and supports. We are a team of compassionate professionals providing person-centered care coordination services for eligible MassHealth ACO and MCO members ages 3-64.

This video is a part of a series of messages from each of our care providers.

Harmony Rivest – Transition Coach

Hi, I’m Harmony Rivest. I am the transition coach with the Care Alliance of Western Massachusetts. I am the person that you talk to you and see every time you were discharged from the hospital or been in the emergency room. So if you’re in inpatient admission I will see you within three business days of when you get out. I can meet you at home which is the most common setting or I can meet you anywhere else that’s more convenient; a library, a restaurant, a family member’s house, anything like that will work. So whatever is best for the patient is what we try and meet. So I’ll meet with you, we’ll go over your discharge paperwork, we’ll talk about any questions that you have, any concerns that you have, or any concerns that your family members may have if they’re there with you. If you need help making appointments if you need help with making an application I can help you with that while I’m there. If you have a long-term need, something that’s more complex, I’ll get in touch with your care coordinator and they’ll be in touch with you to help that process move along. If you’ve been in the emergency room or if you’ve been an observation you’ll get a phone call from me just to check in and see what happened; are you OK, do you need anything, kind of talk to about why you went to the emergency room. If it’s something that you just couldn’t get in with your primary care but it really didn’t need to be the emergency room maybe we’ll give you some options for urgent cares, or a mobile clinic, a way to make it that you’re not stuck sitting in the emergency room for so long waiting to see somebody. The same thing if you have any concerns after your emergency room visit. Anything that’s a long-term need we’ll get in touch with your care coordinator, have them reach out to you, and help you move that process along and get what you need to get. For me, I like being part of this team because it’s very member-focused I like being able to spend some time helping to take some stress off of somebody right when they’ve gotten out of the hospital because generally speaking, they’re not feeling well, they’re stressed out, they’re exhausted, so even something as simple as making an appointment with their primary care doctor for them might not seem like a huge deal. But it’s a big deal for them because they’re not in their best state so it’s really helpful to remember just the little things that we can do to help them feel better.

Care Alliance of Western Massachusetts works with residents of Hampden, Hampshire, Berkshire, and Franklin Counties. We also provide services to residents of Athol, Petersham, Phillipston, and Royalston in Worcester County.

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