Transition Care Plus

Transition Care Plus. House Calls to Provide Follow-up Care to Recently Discharged Patients

Delayed follow-up care and deviations from discharge orders increase the likelihood of being readmitted to hospital.Re-admissions place stress on the health care system, patients and their families.

We work with hospitals and patients, prior to discharge to plan transitional medical care, and then provide in-home follow up care immediately following discharge in Atlanta and surrounding counties.

Transition Care Plus provides a hands-on, house call model of transition care (not TeleMedicine) to manage patients through critical recovery gates after hospitalization and/or surgery. Our care teams work with discharging facilities and patients prior to discharge to plan transitional medical care. Upon discharge, we will immediately perform a follow-up visit in the patient’s home to assess the patient’s condition, as well as social and environmental factors that can affect recovery. Insight gained from a house call follow-up visit helps our care team, in coordination with the discharging facility (and primary care physician), determine if discharge care plans need to be modified based on the patient’s individual post-discharge circumstances, or should be implemented as initially designed.

We implement care plans or revise care plans and monitor patients on a risk determined frequency to minimize any lapses or deviations from the plan of care, and take corrective action based on patients’ response to treatment, all in “close to real time.”

Lastly, we work with Transition Care Plus patient’s primary care physicians to ensure coordination of care and a smooth hand-off at the end of the transition period…if patients so desire. Typically, our Transition Care Plus Patients ask us to assume primary care duties, which we are happy to do.

Better Care. Better Transitions. Better Outcomes
Prior planning, immediate follow-up care and effective hand-offs ultimately leads to improved outcomes and decreases the likelihood that a patient will be readmitted, increases the chances of a patient making a more complete recovery and lowers the overall cost of care.

Call 1-84House-Doc to talk about how Resurgia’s House Call Medical Care can reduce hospital readmission rates and improve transitions in Atlanta.

Transition Care Plus is ideal for:

Case Mangers Planning Patient Care
Discharge Planners Planning Patient Discharge
Hospital Administrators Focused on Improving Outcomes
Post-Operative Patients Preparing For Discharge

Transition Care Plus patients get access to the full spectrum of primary care medical services for acute, chronic and urgent conditions. We offer transitional care for post discharge and post-operative patients for:

Chronic respiratory failure including Tracheotomies and Ventilator Management
Coronary Artery Disease
Congestive Heart Failure
Acute Myocardial Infarction AMI
Chronic Obstructive Pulmonary Disease (COPD)
Joint Replacement e.g. knee and hip
Wound Care Management
Coronary Artery Bypass Graft (CABG)
Pneumonia
Stroke
General Surgeries and Hospitalizations (internal medicine, gynecology, cardiorespiratory, cardiovascular, and neurology services)

We coordinate the following services through high-quality, reliable providers:

Discharging Facility
Home nursing services and home health aids

Phlebotomy (blood draws) and laboratory services
Mobile diagnostics and Imaging including X-Rays (digital radiography), 12 lead electrocardiograms (EKGs), ultrasound, mammograms and pacemaker checks

Pharmacy and prescription management services (medications delivered to your home)
Durable medical equipment such as walkers, wheel chairs and more
IV therapy, such as antibiotics and other medications
Physical, occupational and speech therapy and social work services
Oxygen and respiratory therapy

Costs and Payment

For Hospitals and Medical Facilities participating in the Transition Care Plus Program, Resurgia will bill the participating hospital based on agreed rates. In some cases the full cost of Transition Care Plus may not be covered by the Hospital or Medical Facility and the patient and/or patient insurance will be billed the remaining portion.

Transition Care for Individual Patients

We also provide Transitional Care for Individual Patients following surgery or other hospitalization. We will bill patients insurance (for participating plans) for this services.

No insurance. Not homebound. No problem.

You can pay us directly, and file a claim with your Health Plan. Visits start at $149 plus applicable trip fees and we accept checks and all major credit cards. No cash please.

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