What is Transitional Care?
Transitional care is designed to ensure healthcare continuity and to prevent re-hospitalization of chronically ill patients by providing them with in-home follow-up and an assessment of the patient’s health status, level of support, and goals of care.
Our care assessment team can help patients transition home safely and ensure their health needs are being properly managed.
who qualifies
Anyone 65 years or older with multiple chronic medical conditions and frequent hospitalizations and who are referred by a hospital at the time of discharge.
our services
Our services are based on a consultative relationship with a patient’s primary physician in order to assess patient needs.
Transitional care provides a range of time-limited services which may include:
• Home safety and risk assessment
• Patient health assessment
• Medication reconciliation
Based on patient needs our service team includes:
• Physicians
• Nurses
• Social workers
• Caregivers
• Bath-aides