Specialty Care
Hospital to Home
The first 30 days after discharge carry the highest readmission risk. Transition care is designed to get someone through that window safely.
Why the first month matters
Roughly one in five Medicare patients is readmitted within 30 days of discharge, and a large share of those readmissions are preventable. The usual causes are mundane: a prescription never filled, discharge instructions misunderstood, a follow-up appointment missed, a fall in a home that was not ready.
What transition care covers
- Transportation home and help settling in
- Prescription pickup and medication reconciliation
- Walking through discharge instructions in plain language
- Meal preparation matched to any new dietary restrictions
- Fall-proofing the rooms that will be used most
- Getting to follow-up appointments
- Watching for warning signs and escalating early
Starting before discharge
The best transitions are arranged while the person is still in the hospital. Ask your discharge planner to contact us, or call us directly. We can often have a plan in place within 24 hours.
Talk to someone who knows this condition
Our care coordinators can walk you through what care usually looks like at this stage, what it costs, and what your options are.