Transitioning from one site of care to another poses one of the biggest challenges and risks in modern healthcare. Senior Care Partners aims to help patients make a smooth transition home from the hospital or skilled nursing facility. Following discharge, Senior Care Partners can provide a transition visit, a clinic visit soon after discharge, to ensure a smooth transition back to primary care providers or to provide ongoing medical care for those without an established provider in the community.
Prior to discharge, our physicians and nurse practitioners perform a comprehensive review of each patient’s case in preparation for discharge home. Typically patients are scheduled to see their primary care physician shortly thereafter. However, in between discharge and the time of primary care follow up, issues often arise that can interfere with maintaining optimal health and function.
Our team, having followed the patient from hospital to skilled nursing facility, is well equipped to address these issues. Issues can include confusion about medication changes, unexpected home medical equipment needs, and changes in clinical status. These visits will be targeted to the specific needs identified for each patient in order to smoothly transition their care back over to their PCP. We aim to see patients within 1-2 weeks of discharge in order to address these issues immediately and ultimately to avoid unnecessary re-hospitalizations.