Transitional Care
Hospital to Home
Our flagship 90-day transitional care program reduces hospital readmissions through weekly nurse practitioner house calls, 24/7 triage support, and comprehensive care coordination.
What Is Included
Weekly NP Visits
In-home and telehealth visits with a dedicated nurse practitioner for up to 90 days following hospital discharge. Your NP monitors recovery, manages medications, and coordinates with your care team.
Home Health Collaboration
We work hand-in-hand with your home health agency — signing orders for start of care, labs, UAs, and more. Seamless coordination for better outcomes.
PCP Establishment
Don't have a primary care provider? We help you find one, schedule your first visit, and transfer your records so there's no gap in care after graduation.
24/7 Triage
Before heading to the ER, call us. Our nurse practitioners are available around the clock to assess your symptoms and guide you to the right level of care.
Dietician Services
Telemedicine nutrition counseling to support your recovery. Our registered dietician assesses your needs and develops a personalized nutrition plan.
Who Is This For
Recently Discharged Patients
Patients who have just been released from an inpatient hospital stay and need close follow-up to prevent readmission.
Patients Without a PCP
Individuals who do not have a primary care provider and need help establishing one during their recovery.
Patients With Chronic Conditions
Those managing chronic diseases like heart failure, COPD, or diabetes who need extra support after hospitalization.
Patients at High Readmission Risk
Individuals identified as high-risk for hospital readmission due to medical complexity, social determinants, or lack of support.
What to Expect
First 48 Hours
A nurse practitioner is assigned to your case and an initial in-home assessment is scheduled.
Week 1
First in-home visit is completed along with a full medication reconciliation and care plan development.
Month 1
Weekly visits are established, your care plan is refined based on progress, and home health orders are coordinated.
Month 3
Transition to your established PCP is finalized and you graduate from the program with a comprehensive care summary.
Frequently Asked Questions
Get Started Today
No referral needed. No PCP? No Problem! Call now to start care.
(430) 200-4350Send a ReferralQuick Facts
- Medicare Accepted
- No PCP? No Problem!
- 24/7 Availability
- In-Home and Telemedicine
Ready to Get Started?
Call us 24/7 or send a referral. No PCP? No Problem!