Transition Care

After a hospitalization or surgery, home care may be needed on a temporary or long term basis. We regularly work with hospitals, assisted living, long term care facilities, rehab centers and private care providers to coordinate safe and seamless transitions for their patients when they leave one setting to go to another. Our qualified team of Case Managers collaborates with all caregivers involved to manage multiple, complex medical conditions and ensure a smooth transition for the patient and their family.
We believe that thorough communication and coordination of care can potentially reduce preventable hospital readmissions. This is accomplished through:

• A full review of discharge information, especially the diagnosis and the implications of prescribed medications and treatments in the home.
• A review of potentially serious complications associated with the patient’s medical conditions or prescribed treatments.
• An evaluation of the patient’s support network
• Reconnecting the patient with his/her family physician and other healthcare providers

Our Transition program gives our patients and their families a high degree of satisfaction and confidence that their clinical concerns have been appropriately considered in order to make a successful transition.