Our Care Transitions Program helps ensure the continuity of safe and effective care during the transition from a hospital or skilled nursing facility setting to home. After referral, services provided can include:
- Coordinating the necessary medical equipment and homecare services such as nursing and therapy.
- Obtaining all necessary discharge information from the hospital or skilled nursing facility.
- Facilitating communication and providing assistance with ensuring the patient’s health care needs are met at home.
- Health coaching to improve patient compliance and self-management of their condition.
- Ensuring primary care follow up appointment occurs within 2 weeks.
- Evaluating the patient’s home for any safety risks or concerns.