Our Transitional Care Service is implemented to provide seamless care when our clients are discharging form the hospital or rehabilitative centers. Upon receiving an order from the physician our Senior Care Manager will meet with you in the hospital to develop a personalized care plan that will best assist in meeting all your care needs upon discharge home.
The Senior Care Manager communicates with the discharge planner and hospital physicians to ensure all care needs have been addressed. Clinical treatments usually begin with 24-hours of discharge from the hospital and are based upon the personalized needs of each client to expedite recovery and independence.
We then monitor each patient’s progress daily, weekly or monthly as needed until on-going compliance and optimal results are achieved.
Our Transitional Care
- Senior Care Manager meeting in the hospital prior to discharge home.
- Comprehensive planning with Discharge Planner and Hospital Physician prior to discharge.
- Coordination of Discharge Plans with Hospital, physician, client and client’s family members.
- Development of Personalized Care Plan
- Clinical Treatments initiated within 24-hours of discharge
- Implementation and monitoring of self-management treatment interventions
- Daily, Weekly and Monthly monitoring to ensure optimal results are achieved.