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: