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Transitional Care Program

TRAC - To Reach and Connect


Transitional care is the care that is provided to a patient within the first 30 days of
transitioning from either hospital or skilled nursing facility to the home. Discharging from one environment to another is a critical time where many unnecessary hospital readmissions occur during the first few days.

  • Our liaisons meet with the patient and family prior to discharge to explain what services they will be receiving.

  • To facilitate the transition home, patient involvement prior to the start of care via phone call is crucial to identify and address any potential healthcare needs.

  • The initial home health visit with the patient begins within 24-48 hours following discharge. Medically necessary or high risk patients will be seen within 24 hours.

  • On the first visit medication reconciliation is performed to reduce medication errors and prevent confusion with the many medications often found in a patient’s home.

  • Telephonic communication as well as more frequent visits will be performed during the first crucial week of service.

  • If more than one skilled discipline is ordered (skilled nursing/therapy) we will stagger these visits to keep “eyes on the patient” daily, if possible. This close communication has been proven to reduce and prevent avoidable hospitalizations.


We work in close collaboration with a mobile physician’s group who will see the patient within the first 24-48 hours following discharge. This ensures that we have a following physician for home health orders as well as providing the patient with the convenience of having a provider come to their home. Our providers can return a patient to a skilled nursing facility, if appropriate, rather than sending them to the hospital, thereby reducing healthcare cost.

Through our mobile providers, we can offer the patient:

  • Mobile Podiatry

  • DME

  • Wound VAC’s

  • Mobile Dentistry

  • Mobile Diagnostics

  • Hospice referrals

  • Barium Swallow

  • Ophthalmology

  • In-Home Sleep Studies

  • Placement Assistance

  • Elder Law

  • Caregiving services

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