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Support & Resources

You are 18 years or older with health issues that may have caused a temporary or long term loss of independence. The resource list to your left will help you explore your options or follow the Virginia Navigator link.

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Care Transitions - Hospital to Home

Are you worried about a loved one coming home from a hospital stay? JABA has partnered with area medical facilities to work with individuals making the transition between hospital and home. Our Care Transitions program is based on a nationally-recognized model proven to reduce hospital readmissions and improve health outcomes for patients. A JABA coach helps patients better advocate for themselves as they recover at home.

JABA is available to provide a “health coach” who may visit you in the hospital or skilled nursing facility, and will come to your home after you are discharged to review your medications, prepare for your follow-up appointment with your primary doctor, understand your health conditions and warning signs, and help you set your own personal goals. For the next month, your coach with follow up with you regarding your medical and other support needs, with the goal of lessening the possibility of you needing to return to the emergency room or the hospital. If additional support is needed, the coach will provide links to other JABA programs which can support you in the long term. If this seems like the right plan for you, or you would like more information, please contact JABA’s Certified Care Transitions Coach.

  • Contact:  Amy Leider, Care Transitions Manager
  • Address:
    JABA Main Office
    674 Hillsdale Drive, Suite 9
    Charlottesville, VA 22901
  • Phone:  434-817-3556
  • Open: 8:30 am - 5:00 pm, Monday - Friday

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