Dedicated post-discharge support connecting patients with community resources, scheduling appointments, and ensuring medication adherence. Our innovative program significantly reduces hospital readmissions while improving patient outcomes and satisfaction.
COMPREHENSIVE SUPPORT
Patients are called within the first 48 hours post-discharge from the inpatient setting for initial screening and to determine whether they will approve transitional care.
Assistance with prescription fulfillment, medication reconciliation, and education about proper medication use and side effects.
Help scheduling follow-up appointments with primary care physicians, specialists, and other healthcare providers.
Connecting patients with local primary care physicians, home health services, and community support programs.
Regular check-ins to monitor recovery progress, identify warning signs, and provide guidance on when to seek care.
Clear explanations of discharge instructions, disease management, and self-care strategies for successful recovery.
HOW IT WORKS
Patient receives comprehensive discharge instructions and is enrolled in our transitional care program.
Care coordinator calls within 48 hours for initial screening and to determine transitional care approval.
Review medications, assist with prescription filling, and address any questions or concerns.
Help schedule follow-up appointments and ensure patient understands when and where to go.
Regular follow-up calls to monitor progress and provide continued support during recovery.
Link patient with primary care physician and community resources for long-term health management.
THE IMPACT
Studies consistently show that proper transitional care significantly reduces the chance of returning to the hospital. Our program has achieved remarkable results in preventing readmissions while improving patient satisfaction and health outcomes.
Learn how our transitional care program can reduce readmissions and improve patient outcomes at your hospital.