Transitional care

Enhanced care management upon discharge from hospital or nursing home

Transitional care is intensive, multi-disciplinary management immediately after discharge from a hospital or nursing home. Patient care is often fragmented during these periods and communication between providers may by inadequate. There is significant risk for medication or other errors, which could lead to hospital readmission. Elements of transitional care include

• Contact with physician within 48h of discharge

• Comprehensive physician visit within 7 days of discharge

• Careful review of discharge documentation

• Close coordination with ancillary services such as therapy services and visiting nurses

• Medication reconciliation

• Follow-up of pending results or scheduled appointments with other providers