Any one of these factors can contribute to ineffective transitions in care; poor communication, incomplete transfer of information, or absence of a dedicated and accountable team to facilitate continuity of care.
At Safe and Secure Senior Care, we provide adequate post hospital/transition care for patients transferred from inpatient to post-acute settings.
Our focus is on improving care coordination and community collaboration so as to easily impact health outcomes in patients. To ensure this positive impact on patient outcomes, we render the following transition care services;
- Getting the patients safely home following an inpatient hospital stay.
- Conduct patient assessments and guide post-acute care decisions.
- Help ensure that advanced care planning services are available to discuss goals and care required for the patients.
- Provide patients and families with objective performance, especially with information to help them choose a high-quality skilled nursing facility that is being provided.
- Keeping patients safely at home by reducing avoidable re-admissions.
- Ensure appropriate primary care provider (PCP) follow-up following an inpatient hospital stay.