Transitional Care
Close follow-up in the weeks after a hospital or ED discharge — the window when medication changes go unreviewed and warning signs are easiest to miss. We pick up where the discharge summary leaves off.
Who it is for
- Adults discharged from a hospital or ED within the last 7 days
- Anyone discharged in the last 30 days, or at elevated readmission risk
- Patients discharged after a chronic-condition flare or a complex surgery
- Living in Delaware or Maryland
What we commit to
- An in-home visit within 48 hours of discharge
- Full medication reconciliation against your discharge orders
- Weekly monitoring through the first 60 days
- Warning signs caught before they become readmissions
- A direct line back to your discharge team
Why this window matters
- Patients leave with new instructions, new medications, and a follow-up weeks away
- Signs of decompensation can go unnoticed until they become another ED visit
- Overbooked primary care panels were not built for the first 30–90 days after a stay
- This is the exact window this practice was built around