Key components of successful transitional care include discharge planning and post-discharge follow-up. We can provide consulting to support the entire post-discharge process, whether the patient is discharged directly home or via a skilled nursing facility. Our service provides very specific communication protocols to best ensure patient compliance and care follow-up.
- After-Hospital Care Plan provides a detail patient discharge roadmap
- Post discharge patient contacts at specific intervals to best ensure adherence and follow-up with physicians
- On-site full-time management
- Patient assistance and co-pay assistance
- Guidance to follow patients through skilled nursing and long-term-care (in addition to direct-to-home discharge)