The patient, PCP and the acute care facility by providing a teamwork approach through:
- Continuity of care, by assisting patient reconnect
with their PCP in a timely manner
- Access to a robust network of area
- Reducing emergency room visits
- Improving outcomes by
seeing the patient
within 48 hours of discharge to ensure
- Personalized quality
care in the home
- Medical evaluation and follow-up are completed 3 to 5 days following discharge from the hospital
- Post hospitalization medication reconciliation
- Education of the patient and family members on
medications and other wellness factors
Physician recertifications for homebound patients
Utilizing Transitions House Calls improves a patients health
and quality of life. The physician develops a relationship and
understanding of the patient and their care giver. Patients
receive regular care and follow up while reducing
safety risks and travel time.
The Medical Directors are Internal Medicine or Family Practice board certified physicians with extensive knowledge and experience working with older adult patients who may be medically complex due to multiple diagnosis’s that require monitoring.
Our clinic staff includes a team of Board certified physicians, Nurse practitioners and Physician Assistants.