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Transitional Care Management

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Transitional Care Management

The discharge process is critical when you or a loved one has spent time in a post-acute facility or hospital and are preparing to return home. Discharge planning takes place when the medical and administrative staff of the facility meets with the patient and their family to discuss what needs to happen at home to ensure the best outcome at the time of discharge. Supportive HealthCare Medical HouseCalls refers to this as Transitional Care, which will be tailored to an individual's personalized needs. Transitional care is a broad range of time-limited services designed to ensure health care continuity and promote the safe transfer of patients from one level of care to another or from one type of setting to another. These transitions are a particularly vulnerable point for a patient. Supportive HealthCare Medical HouseCalls can help relieve some of the stress of such changes. We make sure that the medical facility discharge instructions are followed explicitly for the best outcomes and to help reduce the risk of complications or re-hospitalizations.

Taking Care in Your Planning

Supportive HealthCare Medical HouseCalls makes the facility's discharge plan part of the home care plan we develop with you or your loved one.

  • Post-Acute Facility Discharge Follow up visit
  • Chronic Care Management for a qualifying diagnosis
  • Medication Management
  • Acute and Chronic Disease Management
  • Remote Patient Monitoring
  • Telehealth Visits
  • Labs (Offering comprehensive testing), Mobile X-Rays, Ultrasounds, Pharmacy delivery
  • Advanced care planning
  • Clinical support is available by phone 24/7
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