Transition Care Program

In American healthcare today there is often a gap in care from the hospital experience into the home and community health. Patients have difficulty navigating their healthcare at discharge from the hospital due to many factors in a complicated healthcare world. Managing medication reconciliation with home and hospital assigned medications, new diagnosis, multiple providers, and addressing de-conditioning all play a role in the successful transition home.

HomeCall MD LLC wants to help you safely transition from your hospital stay back into your home environment. We will provide a timely post hospital exam and assessment by a Provider to make sure you are continuing to heal. Discharged patients in our program will be seen within 5 business days of hospital stay. We will work with your existing care team including your hospital and primary care doctors.

• HomeCall MD LLC offers a comprehensive transitional care plan in the immediate post hospital period through provider visits to the patient home, assisted or skilled nursing facility.
• Discharged patients will be seen within 5 business days of hospital stay. 
• Medical providers will evaluate patients to make sure they continue to recover as planned.
• Real time home medication reconciliation with patients and available family will be completed. 
• HomeCall MD LLC will work with established primary care physicians and specialists to help ensure a smooth transition from inpatient to outpatient settings.
• After the transitional care evaluation is completed, HomeCall MD LLC will provide a detailed report including medication reconciliation and outstanding action items to the primary care physician.
• Through this close follow up we hope to improve the patient experience after hospitalization.

Please call us to schedule your preferred time. You may receive a call from our office to help facilitate follow up. Reach us at 904-241-3886 today!