Transitional Care Management

Transitional Care Management is designed to support patients as they move from a hospital or skilled nursing facility back to their home or community setting. This period is critical, especially for those with chronic or complex health conditions, as it often involves multiple medications, follow-up appointments, and lifestyle adjustments. At Kare Center, our goal is to ensure a smooth, safe transition by coordinating care, reducing readmission risks, and empowering patients with the tools and guidance needed for continued recovery and stability.

Transitional Care Management Services

Post-discharge follow-up within 48 hours
Medication reconciliation and education
Coordination of follow-up appointments with primary care and specialists
Monitoring for symptoms or complications
Patient and caregiver education and support
Access to a nurse or care coordinator for questions and concerns
Assistance with home care services or equipment, if needed
Review and adjustment of care plan based on patient progress
Mental health and emotional support resources
Communication between all members of the healthcare team

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