Transitional Care

MD at Home understands the challenges that patients and their families face as they transition from a hospital or skilled nursing facility to their home. We recognize these challenges as the primary reason behind facility readmission and patient decline. MD at Home's Transitional Care Team initiates comprehensive transitional care services for recently discharged patients within 48 hours of discharge. Our efforts ensure effective communication between care teams, medication management, post-acute care, and care coordination among the care team and the patient's caregivers, supporting continued recovery and reducing the risk of hospital readmissions.