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Transitional Care Services

How do I know if I need “Transitional Care Services?”

Are you prepared for the transition to home? If you say no to any of the below questions you might want to consider using our Transitional Care Services.

  • Do you have some one that will coordinate the transition from where the facility care stops and where your self-directed care takes over?
  • Do you have some one to take you home?
  • Do you have your place safe and ready for your arrival?
  • Do you have some one to orientate and educate the family and caregivers upon your arrival?
  • Do you have the needed medications, supplies and equipment on hand to continue on with your care?
  • Do you have the knowledge to manage your care?

Our Transitional Care Services provides all of the above for you and more.

Transitional Care Services, starts off with an experienced and trained Transitional Care Manager who will offer a comprehensive, carefully-designed, and absolutely effective transition care program that will make the transition from hospital care to in-home care smoother and safer for the patient.

This will be a step-by-step process that will start at the patients bedside until they are set up in their home. We will provide each patient with a knowledgeable Transitional Care Manager who will guide and educate them through the transition process, make follow-up appointments, monitor and remind them about medications, do a safety and aides check in the home, and provide emotional and mental support. Their progress can be systematically and comprehensively monitored and recorded for their own reference in the future.

What the process covers.


  • Transitional Care Manager does transitional planning intake with patient and discharge planner
  • Meets with discharge planner and receives discharge orders, plan of care and list of any needed supplies and equipment.
  • Picks up any new prescriptions
  • Communicates with patient, family members and facility confirming transition plan and time of transition.
  • Arranges for the patient and their personal items to be picked to take home
  • Communicates with facility informing them of a successful transition and give completed check list.


  • Performs home safety and aids check to prepare the home (if time allows)
  • Checks to see that all needed supplies and equipment are in place.
  • Checks refrigerator for expired food
  • Disposes of old or discontinued medications
  • Brings Patient home
  • Sets up medication dispensing and reviews instructions with Care Recipient
  • Reviews, orientates and educate the Care Recipient and any in-home caregiver the post discharge care plan
  • Arranges for follow-up appointments and check-in’s as per care plan

All of these things, and more, are the highlights of the cost-effective and innovate hospital-to-home transition program that we offer.

nurse holding an elderly woman's hand with caring attitude

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