Transitional Care

What is transitional care?

Transitional care is uniquely designed to meet your medical, physical, and mental health care needs when you return home after being in the hospital, rehabilitation facility, skilled nursing facility, or other in-patient environment.

The providers at Leading MDs have one goal, and that’s to keep you out of the hospital. To reach that goal, they have a 30-day transitional care program that begins as soon as you leave the inpatient facility.

Through their 30-day program, you will recover faster, feel better, and have the tools and resources you need to stay healthy.

In addition to their specialty in internal medicine and behavioral health, the Leading MDs providers also have extensive experience helping patients in hospital and rehabilitation settings. 

Their knowledge allows them to navigate the often complex healthcare system and work closely with community partners to support your return home.

Why is transitional care essential for my well-being?

You face numerous risks to your health after leaving an in-patient facility, including:

• No continuity in your health care
• Functional decline
• Lack of assistive equipment
• Higher risk for readmission
• Danger of delirium (in older adults)
• Poor or no communication with medical providers
• No follow-up on pending lab reports
• Adverse events

You may face adverse events, such as drug interactions, health complications like hospital-acquired infections, and physical weakness (leading to poor health and falls).

It’s also common to discharge patients while they still have lab tests pending, and in many cases, patients don’t learn about the results.

What transitional care services will I receive?

Leading MDs meets with you within 48 hours after your discharge, ensuring you don’t have to worry about gaps in your care.

As part of your 30-day program, they:

• Review your discharge instructions and discuss your next steps
• Confirm your prescriptions are filled and correctly administered
• Help schedule follow-up appointments with all your providers
• Coordinate specialist referrals and appointments
• Create health goals, develop a plan, and help you achieve your goals
• Connect you with community services and resources
• Provide the care needed to prevent avoidable readmissions and relapses
• Ensure you have the ability to manage your health care at home

During your transitional care, your provider is on stand-by for all your needs. When you call, they answer, and you can depend on prompt attention and individualized treatment.

To learn more about transitional care services for yourself or a loved one, call Leading MDs or use online booking to request an appointment.