Transitional Care Management

Did you know that close to 20% of patients are re-admitted to the hospital within 30 days of discharge?
Most of these re-admissions are avoidable!
We will help reduce your risk of re-hospitalization by coordinating your transition from the skilled nursing facility to your home.
We will ensure that during this transitional period you will receive compassionate, quality, and continuative care at the highest standards.

Clear communication of discharge orders to you and your family.
Increase your understanding and compliance of the discharge orders.
Medication reconciliation and explanation of your medications to prevent errors and re-hospitalization.
Prescribe any needed medications.
Order and follow up on any needed labs and tests.
Order any medically necessary home medical equipment such as wheelchairs, hospital beds, oxygen, etc.
Order home health nursing/therapy if needed.
Increase collaboration between all providers care.

We will contact you within 48 hours of discharge.
Medications management and education from our nurse.
Appointment with one of our Providers (MD/NP/PA) within 7 to 14 days of discharge.
Visits at your home or assisted living facility.
Continued monitoring and care-coordination for 30 days post-discharge.
We are not your PCP, you will still follow up with all your regular doctors as scheduled.

Skilled Nursing Medical providers