The Transition Care Program (TCP) Home-Based is a short term support service for the elderly patients after they are discharged from the hospitals. The Transition Care Program aims to provide additional support to help with the transition from hospital to home and support patients while they wait for their long term care arrangements to begin. MD24 House Call is a strategic partner to hospitals and skilled nursing facilities to provide comprehensive transitional care program solutions. Each of our hospital partners is assigned a team of dedicated Care Coordinators and Practitioners who work closely with the hospital staff to ensure that the patient has a smooth transition care program from the hospital to their home after the patients are discharged, and act as a liaison between the hospital and the patient, their family and/or caregiver.
Before the patient leaves the hospital or short-term stay at a skilled nursing facility, the MD24 House Call Coordinator will review, with them, the 30 Day Plan after discharge. This meeting provides patients and their families the opportunity to obtain clarifications and specific details of the plan and to ask any other questions they might have of the staff.
Using MD24 House Call Transitional Care Program services, the Care Coordinator will proactively monitor the patient during this 30-day period and assist with obtaining their related medications and refill information, schedule follow-up doctor appointments, and arrange for transportation services when necessary. The Care Coordinator will contact the patient on a regular basis via telephone to follow up with their care, answer questions, and refer them to the proper care provider if any problems arise.
MD24 House Call is the bridge connecting healthcare providers, patients and support services in Transitional Care Program services. Our Care Coordinators will work closely with the existing hospital discharge department to coordinate patient care and provide reports on patient readmission rates. In addition, we will identify specific medical and skilled nursing facilities with high patient readmission and provide them with our specialized workflow analysis and consultative services to help reduce future hospital readmission. For more information on comprehensive MD24 Transitional Care Program Services, please contact MD24 (888-632-4758) or visit our website at www.md24housecall.com