Transitional Care is a healthcare model and philosophy which recognizes that care for chronically ill patients is often fragmented, leading to high risk for re-hospitalization and decline. Transitional care emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management - all accomplished with the active engagement of patients and their family and informal caregivers and in collaboration with the patient's physicians.

ElevateHealth supports the Transitional Care Model by providing a nurse case manager to assist high risk patient's in their transition from hospital to home. The nurse first sees the patient while in the hospital and will help coordinate discharge with the patients physician and hospital case manager. Upon discharge from the hospital, the transitional care nurse will see the patient within 24-48 hours of discharge. In addition to the hospital visit and initial home visit, the transitional care nurse will also help coordinate care with the patients physicians, other home health nurses, and the patient - through ongoing telephone contact.

Transitional Care Nurses are expert case managers and trained in chronic disease management strategies and care.

For more information on how we can support Transitional Care initiatives, please call Elevatehealth at (800) 880-1405.