Transitional Care

Transitional Care services

For many families, the day a loved one is discharged from the hospital feels like a turning point, and the focus shifts to healing at home. Yet medical research shows, post OP is one of the most vulnerable times in a patient’s journey. Reports show that nearly 1 in 5 Medicare patients is readmitted within 30 days of leaving the hospital, often due to issues that could have been prevented with the right support.

Transitional healthcare is designed to provide that support. It serves as a bridge between the hospital and home, ensuring that patients and their families are not left to manage recovery on their own. Transitional care typically begins the moment of discharge and continues for about 30 days. During that time, the emphasis is on continuity, clear communication, and careful oversight. Patients receive follow-up calls, medication reviews, and guidance about upcoming appointments. Families gain a direct line of support to help answer questions, clarify instructions, and recognize early warning signs before they become emergencies.

The benefits of this approach are clear. National studies show that transitional care programs effectively reduce hospital re-admissions. Families consistently report feeling more confident and less overwhelmed when they know there is a care team helping to navigate the post-hospital period.

Medication management is a particularly critical piece of transitional care. Confusion over prescriptions is one of the most common reasons patients return to the hospital. Transitional care teams reconcile medications, making sure patients are not accidentally taking duplicates or experiencing harmful drug interactions. They also provide education about what to expect and when to seek help, empowering families to play an active role in recovery.

At its core, transitional healthcare is about protecting progress. The hard work of recovery does not end when a patient leaves the hospital doors. In fact, it is often just beginning. By providing families with the guidance and tools they need, transitional care gives patients the best chance to heal safely, avoid setbacks, and return to daily life with confidence.

Q&A

Transitional Care Q&A

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Transitional care is uniquely designed to meet your medical, physical, and mental health care needs when you return home after being in the hospital, rehabilitation facility, skilled nursing facility, or other in-patient environment.

The providers at Leading MDs have one goal, and that's to keep you out of the hospital. To reach that goal, they have a 30-day transitional care program that begins as soon as you leave the inpatient facility.

Through their 30-day program, you will recover faster, feel better, and have the tools and resources you need to stay healthy.

In addition to their specialty in internal medicine and behavioral health, the Leading MDs providers also have extensive experience helping patients in hospital and rehabilitation settings.

Their knowledge allows them to navigate the often complex healthcare system and work closely with community partners to support your return home.

You face numerous risks to your health after leaving an in-patient facility, including:

  • No continuity in your health care
  • Functional decline
  • Lack of assistive equipment
  • Higher risk for readmission
  • Danger of delirium (in older adults)
  • Poor or no communication with medical providers
  • No follow-up on pending lab reports
  • Adverse events

    • You may face adverse events, such as drug interactions, health complications like hospital-acquired infections, and physical weakness (leading to poor health and falls).

    It's also common to discharge patients while they still have lab tests pending, and in many cases, patients don't learn about the results.

    Leading MDs meets with you within 48 hours after your discharge, ensuring you don't have to worry about gaps in your care.

    As part of your 30-day program, they:

  • Review your discharge instructions and discuss your next steps
  • Confirm your prescriptions are filled and correctly administered
  • Help schedule follow-up appointments with all your providers
  • Coordinate specialist referrals and appointments
  • Create health goals, develop a plan, and help you achieve your goals
  • Connect you with community services and resources
  • Provide the care needed to prevent avoidable readmissions and relapses
  • Ensure you have the ability to manage your health care at home

    • During your transitional care, your provider is on stand-by for all your needs. When you call, they answer, and you can depend on prompt attention and individualized treatment.

    To learn more about transitional care services for yourself or a loved one, call Leading MDs or use online booking to request an appointment.