Transitional Care

Cornerstone House Calls provides follow-up care to recently discharged patients. Changes from discharge orders increase the probability of being readmitted to the hospital. We can help improve outcomes and prevent recurrent ER visits and hospital readmissions.

We work with hospitals and patients, prior to discharge, to plan transitional medical care and provide in-home follow up care.

Transitional Care provides a hands-on, house call model of care to manage patients through critical recovery periods after hospitalization and/or surgery. 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 may affect recovery. Insight gained from a house call follow-up visit helps determine if discharge care plans need to be modified based on the patient’s individual post-discharge circumstances.

We implement care plans or revise care plans while monitoring patients on a risk determined frequency. We strive to minimize any lapses or deviations from the plan of care, and take corrective action based on the patient’s response to treatment.

We work with the patient’s primary care physician to ensure coordination of care and a smooth transition from our acute care.

The goal of Transitional Care is to decrease the likelihood of a patient being readmitted, increase the chances of a complete recovery and lower the overall cost of care.

Transitional Care is Ideal for:

• Case Managers & Discharge Planners Planning Patient Discharge
• Hospital Administrators Focused on Improving Outcomes
• Post-Operative Patients Preparing for Discharge