Transitional Care Services: Smooth Transitions for Better Health
Smooth Transitions for Better Health
At GreenWell Health in Cave Creek, Arizona, we understand that transitioning from one healthcare setting to another can be a complex and stressful time for patients and their families. Whether you are moving from a hospital to home, from a skilled nursing facility back to independent living, or even transitioning after surgery, our Transitional Care Services ensure that your recovery and health management are smooth, efficient, and well-coordinated.
Transitional care refers to the coordination of healthcare during a patient's movement between different healthcare settings — such as from a hospital to home or between rehabilitation centers and skilled nursing facilities. Our goal is to support each patient in their recovery, reduce the likelihood of complications, and prevent unnecessary hospital readmissions. Through continuous communication, patient education, and follow-up care, GreenWell Health delivers a robust care plan tailored to each patient's needs.
​How Our Transitional Care Program Works
Our Transitional Care Services at GreenWell Health are designed to make sure patients don't fall through the cracks during their transition. We follow a structured, patient-centered approach that includes:
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Comprehensive Care Coordination
We ensure all relevant parties — including the hospital, skilled nursing facility, inpatient behavioral health facility, primary care provider, and other healthcare professionals involved in the patient's care — are aligned and informed. Effective communication is key to ensuring no details are missed, helping prevent potential complications during the transition process.
Medication Management and Education
One of the most critical aspects of transitional care is medication management. We work with the patient and their caregivers to reconcile medications, ensure proper understanding of dosage, and explain how to manage any changes made during the hospitalization. We also provide necessary education to reduce medication errors, a leading cause of readmissions.
Post-Discharge Follow-Up
Our team takes a proactive approach to follow-up care. We will contact the patient in one of three ways:
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Phone Call
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Telehealth
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Home-Visit
This ensures that any issues or concerns that may arise after discharge are addressed immediately, helping to avoid complications that could lead to readmission.
Appointment Scheduling and Coordination
We take the responsibility of scheduling follow-up appointments and any necessary diagnostic tests or treatments. By coordinating these appointments before discharge, we ensure that the patient’s recovery progresses without delays and that they receive timely care.
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Patient and Caregiver Education
A key part of our services is educating both patients and caregivers. We explain the patient's condition, treatment plan, and self-care techniques to ensure everyone involved understands how to manage care effectively. The goal is to empower the patient and their caregivers with the knowledge and resources needed to manage recovery at home.
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Primary Care Services
If a patient does not have an existing primary care provider (PCP), our team can assume this role during the transitional care management (TCM) period. Once this period ends, we seamlessly return the patient to their regular PCP, ensuring continuity of care. If a primary care provider is already in place, we work closely with them to ensure the patient transitions smoothly back into their care.
Who Benefits from Transitional Care?
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Our Transitional Care Services are ideal for patients who are being discharged from:
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Hospital Settings (Acute Care)
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Skilled Nursing Facilities (Post-Acute Care)
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Rehabilitation Centers
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Surgery Centers / Surgeons' Offices
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Transitional care is especially beneficial for patients who are:
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Managing chronic conditions
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Recovering from surgeries
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Transitioning from rehab or post-acute care
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Older adults requiring additional care during discharge
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Patients with complex health conditions that need a smooth, coordinated recovery plan
Benefits of Transitional Care Management
Transitional Care Management (TCM) helps patients avoid gaps in care, significantly reducing the risk of readmissions and complications. Below are some key benefits:
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Prevents Readmissions through Early Intervention
By intervening early in the transition process, our team can identify potential issues before they escalate. Early intervention is proven to reduce hospital readmissions, saving both time and money for healthcare facilities and patients alike.
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Cost Savings Across the Healthcare System
TCM services reduce the overall cost of healthcare by improving the efficiency of patient transitions, avoiding unnecessary readmissions, and optimizing care coordination. It also reduces the financial burden on patients by minimizing unexpected hospital visits.
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Bridges the Gap for Access to Care
The transitional care process bridges the gap between various healthcare settings, ensuring that the patient has continuous access to the right care when needed.
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Supports Disease Management and Continuity of Care
Our team helps manage chronic diseases, ensuring that patients adhere to their care plan and receive continuous monitoring and support during the transition process. This ongoing support helps stabilize the patient’s condition and improve long-term outcomes.
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Helps Overcome Discharge Barriers
Discharge can sometimes be a confusing and stressful process for patients and caregivers. Our transitional care program works to alleviate these challenges by guiding the patient and their caregivers through the necessary steps, including post-discharge needs, scheduling, and ongoing care.
The Impact of Transitional Care on Patient Readmissions
Each year, approximately 17,197,683 patients are readmitted to the hospital in the U.S., with 20% of those readmissions being avoidable. By implementing Transitional Care Management, GreenWell Health aims to significantly reduce these numbers. Our team’s proactive approach ensures that patients receive the support they need during vulnerable periods and can transition to home with confidence.
How to Enroll in Transitional Care Services
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Contact us — Whether you're a patient or a family member, you can reach out to us directly or through your healthcare provider to enroll in our transitional care program.
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Coordinating with your healthcare team — Once enrolled, we begin the coordination process with all your providers to make sure everything is in place for your transition.
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Scheduling follow-ups — Our team will take care of scheduling and ensuring that the right appointments are made at the right time, ensuring no gaps in care.
If you or your loved one would benefit from these services, don’t hesitate to reach out to GreenWell Health for more information and to get started.
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Explore our full services at GreenWell Health: GreenWell Health
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Contact us for more details: Contact Us
Getting started with Transitional Care Services at GreenWell Health is simple:
Total Number of Patients Readmitted Every Year: 17,197,683
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At GreenWell Health, we are dedicated to ensuring that your transition from hospital to home or another healthcare setting is smooth, safe, and well-supported. If you or a loved one is transitioning between care settings, reach out to us today to learn how we can support you every step of the way.
Benefits Of Transitional Care Managment
Prevents readmission through early intervention (Saves Hospital money)
Universal reduction in total care costs
Creates a bridge for access to care
Helps patient to overcome discharge barriers
Proactively connects patients with the right services
Supports disease management by optimizing continuity of care
Helps determine correct level of care needed