The practice of transitional care management (after stays at Hospital, SNF, Rehab. & Behavioral Health) aims to identify and overcome barriers to successful transitions and prevent gaps in care. The goal is to improve the patient experience while saving the health care cost of readmission.
TRANSITIONS OF CARE SERVICES OVERVIEW:
• Start Discharge at the Time of Admission
• Ensure Medication, Education Access, Reconciliation & Adherence
• Arrange Follow-up Appointments with PCP
• Arrange Home Healthcare & CPO
• Have Patients Teach-Back the Transitional Care Plan