Transitional Care
An extension of a multi-specialty practice providing quality care to post-acute patients. We help you transition safely from the hospital back to the comfort of your home.
What Is Transitional Care?
Transitional care assists people in moving from one care setting to another — typically from a hospital or rehabilitation facility back to home. We provide personalized care and support during these critical transitions.
Our nurse practitioner conducts an initial assessment at the patient's home within 24 to 48 hours of discharge, followed by a comprehensive point-of-care evaluation and ongoing nursing and/or therapy services.
Patients continue with their own physicians during the transition. We coordinate closely with your healthcare team to create a comprehensive care plan that ensures a safe and successful return home.
Higher Level of Care
- No visit limits when medically necessary
- Nurse practitioner supervision overseen by a medical director
- All visits managed according to appropriate care levels
- Accepts patients with higher acuity levels
- NP assessment within 24-48 hours of discharge
What's Included in Transitional Care
Medication Management
Thorough medication reconciliation and management to prevent adverse drug events after discharge.
Wound Care
Professional wound assessment and treatment by experienced nursing staff.
Recovery Planning
Customized recovery plans developed with your healthcare team for optimal outcomes.
Fall Prevention
Home safety assessment and fall prevention strategies tailored to your environment.
Care Coordination
Seamless communication between your physicians, specialists, and our care team.
Readmission Prevention
Proactive monitoring and intervention to prevent hospital readmission within 30 days.
Coming Home from the Hospital?
Let us help ensure a safe and smooth transition. Call us today.