Transition of Care

When you are admitted to the hospital, you receive regular care around the clock. But what happens after you are discharged? As you prepare to leave the hospital, it’s critical to have a clear path in place and to follow your discharge instructions. You may need to arrange follow-up visits or manage multiple medications, and that’s where we can help.

Through our Transition of Care program, our dedicated nursing care team helps manage and support your transition of care after discharge from a hospital or rehabilitation program to reduce the potential for readmission. We engage and coordinate with health systems, clinicians, caregivers and patients to ensure safe and successful transfers from inpatient or post-acute levels of care to outpatient facilities or home. We follow your care transition journey while ensuring all providers are connected and informed.

In partnership with your provider, we:

• Identify and manage patients to ensure safe transitions
• Reduce readmissions through effective assessment and intervention
• Build accountability with patients to understand and actively manage care
• Reconcile medications to prevent complications
• Recognize symptoms of illness to guide care decisions
• Modify care plans to reflect new needs
• Identify social determinants of health

We are able to connect you with pharmacists, community resources, care and case managers, and additional resources to ensure you remain on the road to recovery.