Welcome to Transitional Care Services

TransitionalCareServices.com encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings. 

High-quality transitional care services are especially important for older adults with multiple chronic conditions and complex therapeutic regimens, as well as for their family caregivers. These patients typically receive care from many providers and move frequently within health care settings. A growing body of evidence suggests that they are particularly vulnerable to breakdowns in care and thus have the greatest need for transitional care services. Poor “hand-offs” of these older adults and their family caregivers from hospital to home has been linked to adverse events, low satisfaction with care, and high re-hospitalization rates. 

Many factors contribute to gaps in care during critical transitions. Poor communication, incomplete transfer of information, inadequate education of older adults and their family caregivers, limited access to essential services, poorly planned transitions and the absence of a single point person to ensure continuity of care all contribute to mis-managed transitions. 

With our on-demand Transitional Care Managers we ease the burden of you or your family members by arranging for all the care and resources necessary for a post-hospital discharge. From the planning and coordination, to delivering the patient home safely, to assessing the home safety and environmental conditions, we make sure that they have a safe transition. We will also integrate an innovative and effective system to improve their medication adherence and make sure that any expired and discontinued medications are disposed before they can cause any health issues.

How do you know if you need Transitional Care Services?

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