Understanding Transition of Care
A hospital stay oftentimes causes a disruption to daily life for both the patient and caregivers. Transition of Care is necessary when it’s time to leave the hospital and the round-the-clock care of the hospital staff. Transition back home is an important step after a hospital stay. Sometimes patients have medications, rehabilitation, follow-up instructions, changes to lifestyle and so on. Patients should connect with their primary care doctor within a certain amount of time after being discharged from a hospital stay.
Community Care Physicians’ Transition of Care Program is a post-hospital discharge program to help support patients leaving the hospital to reduce the chances of returning to the hospital unnecessarily. Our team ensures that patients are prepared once they have returned home from the hospital.
The purpose of this program is to:
- Facilitate a smooth transition from the hospital to home for patients
- Work with patients to identify any barriers to a successful transition to help remove those barriers
- Continue to support patient recovery and health
- Prevent readmission to the hospital
How our Transition of Care Program Works
If you have a primary care doctor within Community Care Physicians, your doctor will be notified of your hospital stay and someone from the office will contact you within a few days of your discharge (typically within 24-48 hours). Your primary care team will arrange any follow-up visits required.
If you do not have a primary care doctor or if your doctor’s office can’t immediately schedule you for a transition of care visit, CCP’s Transition of Care team will assist with your follow-up visit. This team will schedule a visit with you to review your hospitalization, address ongoing health concerns, and create a plan for you going forward. This visit is part of a transitional program to provide care for a limited amount of time. You will automatically graduate from our transition care program, and for ongoing medical care, you will need to establish with a primary care physician (or schedule with your CCP primary care physician).