Transitional Care Program
“Reducing readmissions by working together with your care providers”
DHCS partners with hospitals, nursing homes, home health providers and their family members to transition patients back to their homes by providing comprehensive continuation of care to help reduce hospital and nursing home readmissions, while focusing on good physical and mental health.
Our Program
- Dedicated Care Coordinator for each facility (Hospital)
- Pre and Post Discharge calls to each patient and family member
- In-home visit by a Nurse Practitioner within 2-5 days of discharge
- Clinical Staff availability 24/7 for 30 days post discharge for each patient and their family
- Work directly with Social Services and Case Managers within the facility
- Nurse Practitioners provide additional in-home visits if necessary
- Work directly with other community Medical Providers for improved continuity of care
- Weekly reports to facility partners on status of current patients under management
Program Cost
- The Transitional Care Program is available to all facility partners at no cost. We fund all operations through each clinical visit provided to the patient and billed to their insurance
Serving the Greater Tampa Bay area