Transitional Care Process
Transitional care is a relatively new process utilized to transition the patient from the acute hospital or post-hospital skilled rehabilitation setting to the home. It also is designed to ensure that the patient does not require a re-admission to the hospital for the same illness within a thirty day period.
Integrated Plans utilizes a transitional care Registered Nurse (RN) who is available to the patient 24/7 to intervene in a medical crisis or simply to answer a patient’s question that if unanswered could result in an unnecessary emergency room visit or other medical service.
The transitional care RN has the authority to involve the patient’s physician or to arrange a telemedicine visit. This is the appropriate integration of patient care, technology, convenience for the patient and their family and medical effectiveness.