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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

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  • 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.

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

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

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

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

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

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