Care Transitions
We ensure the continuity of safe and effective care during the transition from a hospital or skilled nursing facility setting to home using industry best practices. 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 your health care needs are met at home.
- Health coaching to improve compliance and self-management of your condition.
- Ensuring primary care follow-up appointment occurs within 2 weeks.
- Evaluating the your home for any safety risks or concerns.