Transitional Care
Rehab to Home
Our transitional care program for patients leaving rehabilitation facilities ensures a safe return home with weekly NP follow-ups, rehabilitation coordination, and comprehensive home safety evaluations.
What Is Included
Weekly NP Follow-Ups
Dedicated nurse practitioner visits in your home to monitor your recovery progress, manage medications, and ensure your rehabilitation goals stay on track.
Rehabilitation Coordination
We coordinate directly with your rehab facility, physical therapists, and occupational therapists to maintain continuity of care after discharge.
Medication Management
Thorough medication reconciliation and ongoing management to prevent adverse drug interactions and ensure adherence to your prescribed regimen.
Fall Prevention Assessment
Comprehensive evaluation of fall risk factors with personalized strategies to keep you safe as you regain strength and mobility at home.
Home Safety Evaluation
An in-home assessment to identify potential hazards and recommend modifications that support your independence and recovery.
Who Is This For
Post-Rehab Patients
Patients being discharged from skilled nursing or inpatient rehabilitation facilities who need continued monitoring at home.
Patients Recovering From Surgery
Individuals who underwent joint replacement, cardiac surgery, or other procedures and completed an initial rehab stay.
Patients With Mobility Challenges
Those who have experienced a decline in mobility and need support transitioning safely back to independent living.
Elderly Patients Transitioning Home
Older adults who face a higher risk of falls, medication errors, and readmission when returning home from a rehab facility.
What to Expect
First 48 Hours
A nurse practitioner is assigned and an initial home assessment is scheduled before or shortly after your rehab discharge.
Week 1
First in-home visit with a complete medication reconciliation, fall risk assessment, and home safety evaluation.
Month 1
Weekly visits continue with ongoing rehabilitation coordination, therapy progress tracking, and care plan adjustments.
Month 2-3
Visit frequency adjusts based on your progress. PCP transition is prepared and you graduate with a full 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!