Transition to Home Care
About Services
Let Us Help You Transition To Care Gracefully!
Are you getting discharged from the hospital, skilled, or rehabilitation facility and realize you will need some help at home?
Is your loved one struggling with a disability, injury, or health concern? Did you recently fall? Are you recovering from surgery?
Have you been diagnosed with a chronic illness such as.,
- Stroke
- Cancer
- Heart Failure
- COPD
- Dementia
- And more…
Navigating Care
Graceful Transitions for Your Loved Ones
Transitioning home from the hospital, skilled nursing facility, or acute rehabilitation can be difficult. Our transitional care services is designed to make the transition from a medical facility to home seamless. We offer a unique approach to those struggling with a health condition. Comprehensive support with expertise and empathy is necessary to enhance quality of life.
Reasons why people return to the hospital:
1/3 of readmitted patients reported seeing doctors between hospitalizations. The patient may need help with transportation, remembering the appointment, or the appointment is scheduled too far out.
Transitional Care Program
We are experts at transitioning you safely home from a hospital, skilled, or rehabilitation facility.
Let our team follow you home.
- Our team will coordinate care with doctors and nurses to ensure discharge instructions are implemented at home.
- Our interdisciplinary team will consult with families and our team to provide education for medically complex cases.
- Caregivers will report any potential change in condition to our interdisciplinary team for early intervention and hospital prevention.
- Upon discharge, we can transport you home, obtain prescriptions, and assist with follow-up appointments.
- We can provide care daily, for a few hours, or 24/7, every day of the week.
Get Access To Our Services Today
We offer Seamless Access to Care, because All Problems Have Solutions.
Our process at Hearts for Dementia is designed to provide personalized solutions to your unique needs.
Consult With Us
Discuss your concerns and requirements with our experienced team for personalized guidance.
Identify Service Need(s)
Work collaboratively to identify the specific services that will best meet your needs.
Schedule an Appointment
Set up a convenient appointment to initiate the care and support you or your loved ones deserve.
How We Stand Out in Transitional Care
Your Seamless Path to Home Health Happiness
We distinguish ourselves by providing an effortless transition from hospital discharge to home.
Consult With Us for Pricing Details.
Appointment
Request an Appointment
Your Journey Starts With a Conversation
Take the first step towards enhanced well-being by scheduling an appointment, where personalized care begins with understanding your unique needs.
Customer Service
Address
9375 E Shea Boulevard, Suite 100, Scottsdale, Arizona 85260
FAQs
Medicare typically covers transitional care services for up to 30 days after a patient is discharged from an inpatient hospital stay. This 30-day period helps individuals transition back to a community setting, ensuring they receive necessary care, such as follow-up appointments, home visits, and medical support. To qualify, a physician must approve the services. Transitional care services help prevent complications and ensure a smooth recovery after a hospital stay, reducing the risk of readmission.
To qualify for a Transitional Care Management (TCM) visit, a patient must complete certain steps after being discharged. Within two business days, the provider contacts the patient or caregiver. A face-to-face visit follows within 7–14 days, depending on the level of care needed. Medication management is reviewed by the visit date, and additional support services are provided, like reviewing discharge notes and patient education. The visit involves moderate to high decision-making to ensure a smooth transition through transitional care services.
Transitional home care supports individuals as they move from a care facility, like a hospital, back to their home. This temporary care focuses on creating a customized care plan to meet the patient’s needs, prevent rehospitalization, and ensure continued high-quality care. Services often include skilled nursing, medication management, meal planning, and assistance with daily activities.