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.