Returning home after a hospital stay or skilled nursing facility can be challenging. Patients may need to manage new medications, follow updated care plans, attend follow-up appointments, or adjust to changes in their health.
Care One Health provides post-acute care transition support to help patients move from a healthcare facility back to their home with greater coordination, confidence, and continuity of care.
What Are Post-Acute Care Transitions?
A post-acute care transition is the process of moving from a hospital, skilled nursing facility, or other healthcare setting back home.
During this time, effective communication and follow-up are important. Care One Health helps patients and their families understand and coordinate the next steps in their care while remaining connected with their healthcare providers.
How We Support Your Transition
Our post-acute care services may include:
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Care After Discharge – We provide support following discharge from a hospital or skilled nursing facility to help patients continue their care at home.
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Medication Coordination – We help coordinate medication information and support patients in understanding changes to their medications following discharge.
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Care-Plan Coordination – Our team helps coordinate the patient’s updated care plan with the appropriate healthcare providers and members of their support system.
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Follow-Up With Healthcare Providers – We help support communication and follow-up with healthcare providers to ensure ongoing healthcare needs are addressed.
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Support for Healthcare Goals – We work with patients and their care teams to support specific healthcare goals following discharge.
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Rehospitalization Risk Reduction – Coordinated follow-up and continued support can help identify potential concerns early and reduce the risk of complications and rehospitalization.
Who May Benefit?
Post-acute care transition support may be helpful for patients who:
- Are returning home after a hospital stay
- Have recently been discharged from a skilled nursing facility
- Have changes to their medications or care plan
- Need follow-up with multiple healthcare providers
- Have ongoing or complex healthcare needs
- Need additional support adjusting to care at home
A Smoother Transition Home
Leaving a healthcare facility is only one step in the recovery process. Care One Health helps patients stay connected to the care and support they need after returning home.
Our goal is a smoother transition, better follow-up, and continued support at home.