Transition Management

For many of our patients, their care begins with a referral from a hospital or rehab facility. Our care transition specialists are available to meet with patients before they go home, helping them and their families to prepare for a successful home care experience. More than a simple meeting, this service enables patients and families to have a clear understanding of what to expect, what resources are available to them and the preparation necessary to get the most from their home care experience. –>Our team of clinical and community liaisons help patients feel comfortable and confident upon leaving the hospital or skilled nursing facility before returning home. Our liaisons can meet a patient in an in-patient setting and evaluate any outstanding steps in the discharge process – eliminating any negative consequences on the patient’s health, quality of life or patient satisfaction with care.

The goal of our program is to maintain the continuity of care from in-patient care to home care.

  • Assistance in the development of a plan of care prior to discharge
  • Education for the patient regarding their home care needs and services
  • Confirmation of medications
  • Review of ADL capabilities
  • Assessment for fall risk
  • Discussion of family involvement
  • Assistance in scheduling follow-up appointments with primary care physician and specialists