Transitional Health Care

What is Post-Discharge Transitional Care?

Transitional care is a word that refers to the 30 days following hospital discharge. Transitional healthcare service is a collection of actions meant to guarantee that a patient’s health care is coordinated and continuous. 

Transitional care management is predicated on the accessibility of health care practitioners who are well-trained in chronic care and have current knowledge of the patient’s objectives, preferences, clinical state, and a thorough plan of treatment. It entails logistical planning, patient and family education, and communication among the health care providers participating in the transition. Persons with complex care requirements require transitional care, which includes the sending and receiving components of the move.

What Does HomeMD Have To Offer?

Our HomeMD transitional care management Services team is made up entirely of registered nurses who organize post-hospitalization care to ensure that our patients never fall through the healthcare gaps. In addition, our automated software systems “speak” to the hospital’s software systems, allowing us to be alerted instantly and smoothly when our patients are admitted to hospitals, even if they are too unwell, preoccupied, or distracted by their disease let us know.

Our transitional care nurse gets to work as soon as our systems are detected, quickly working with hospital discharge planners to ensure that post-hospitalization treatment is seamless and well-coordinated. In addition, our transitional care nurse contacts the patient or their family after release to schedule a post-hospitalization visit. This visit would take place within a 14 business day time frame from when the patient has been discharged. Either the patient’s Primary Care Physician or someone else from our amazing medical staff will be conducting this visit. If the visit happens to be from one of our medical staff it’s going to be done via a TeleHealth visit.

We take great pride in knowing that we accomplish what others can’t at HomeMD transitional care management services. We see our patients quickly after discharge, whether onsite or telephonically driven. Our transitional care management team then follows up with our newly hospitalized patients every few days to ensure that they are doing well. In addition, we collaborate with all of the home health nursing firms to aid their nurses by answering their inquiries and validating their concerns.

Why Choose Us?

We’ll place you at the center of all we do, and we’ll establish and implement a support plan that meets your goals. Your assistance package will be reviewed regularly to see how far you’ve progressed toward your objectives. We take a ‘baby steps’ approach to achieve your objectives. Everyone is unique, and each person will require assistance developing their talents at their rate. Our transitional care management services will assist you in gaining independence or managing your life to the best of your abilities within your limitations.

Arrange a Visit

Please feel welcome to contact our friendly reception staff with any general or medical Inquiry call us.

Business Hours

Monday – Friday 8.00 am – 5:00 pm
Answering Service 5.00 pm – 8:00 am

Urgent tele visits with a practitioner:

Week Days  5.00 pm – 12:00 am
Weekends 10.00 am – 4.00 pm

Note: After this time will be added on to the urgent tele visit list for the following morning.