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Transitional Care Services

Supporting safe, seamless recovery for patients after hospital or rehab discharge — fully remote for all outside of Long Island, NY

Face-to-face visits offered for patients discharged from nursing homes or rehab facilities who require therapy 

  • Long-term rehabilitation assessments - Comprehensive health evaluations for patients recovering from surgery, illness, or injury in collaboration with rehab teams

  • After hospital or rehabilitation stay transition care management - Follow-up appointments and medication reconciliation to ensure a safe and smooth recovery at home or facility.

  • On-call support for rehabilitation and long-term care facilities - Telehealth access and clinical decision support for urgent medical needs or ongoing monitoring

  • Collaboration with facility staff and families - Coordinated communication and care planning with multidisciplinary teams and family caregivers.

  • Chronic condition oversight in rehab settings - Continued management of underlying chronic conditions during post-acute recovery.

  • Coordination with physical therapy, occupational therapy, and speech therapy - Integrated care planning with licensed therapists for optimal patient recovery.

  • Home care services collaboration - Partnering with home health nurses and nursing assistants to support patients' medical and personal care needs.

Virtual follow-up visits

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Virtual follow-up visits within 24–72 hours of discharge ensure patients get timely medical attention as they transition home from the hospital or rehab. These remote check-ins, done via secure video or phone, allow healthcare providers to review recovery progress, address concerns early, and reinforce care instructions—helping to prevent complications or readmissions.

Full medication reconciliation

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Full medication reconciliation and review via secure video or phone helps ensure patients are taking the right medications safely after discharge. A healthcare provider reviews all prescriptions, over-the-counter drugs, and supplements to check for accuracy, interactions, or duplications. This process helps prevent medication errors and supports a smoother recovery at home.

Scheduling and coordination of follow-up appointments

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Scheduling and coordination of follow-up appointments ensures patients stay connected to the care they need after discharge. Whether it's with your primary doctor or a new specialist, the care team helps arrange and confirm appointments, removing the stress of navigating the healthcare system alone. This support keeps recovery on track and helps avoid gaps in care.

Personalized education on discharge instructions

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Personalized education on discharge instructions, new diagnoses, and home care plans empowers patients to confidently manage their health at home. Healthcare providers explain medical terms, care routines, and next steps in simple, easy-to-understand language. This tailored guidance helps reduce confusion, improves treatment adherence, and supports a safer, smoother recovery.

Ongoing virtual symptom monitoring

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Ongoing virtual symptom monitoring allows healthcare providers to regularly check in on a patient’s condition from a distance. Through phone calls, video visits, or connected devices, symptoms are tracked to spot potential issues before they become serious. This proactive approach helps prevent complications and reduces the likelihood of hospital readmission.

Coordination with in-home care providers

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Coordination with in-home care providers ensures patients receive the right support directly where they live. The care team works closely with home health nurses, aides, or therapists to align on care plans, track progress, and address any concerns. This collaboration helps maintain continuity of care and supports a safer, more comfortable recovery at home.

Durable medical equipment (DME)

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Help with durable medical equipment (DME), prescription refills, and pharmacy delivery ensures patients have the essential tools and medications they need for recovery at home. The care team assists with ordering equipment like walkers or hospital beds, managing medication refills, and arranging convenient delivery services.

Social needs evaluation uses remote screening to identify challenges like food insecurity, lack of transportation, or home safety risks. Patients are then connected to local resources and support services to help remove barriers to healing and promote overall well-being.

Emotional wellness check-ins and referrals

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Emotional wellness check-ins and referrals to virtual mental health support help address the stress, anxiety, or loneliness that can arise during recovery. Patients receive compassionate check-ins and, if needed, are connected to licensed therapists or counselors through secure virtual platforms.

Direct communication with your hospital team, primary care, and specialists ensures everyone involved in your care is on the same page. This coordinated approach helps avoid confusion, reinforces treatment plans, and supports a smooth, well-organized transition from hospital to home.

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