Transitional Care Management

Transitional care management makes it easy to keep up on the care and services you need after a discharge from an inpatient facility. VirtuaReal Health offers virtual and remote transitional care management to help you avoid hospital or rehab readmission. To set up a virtual transitional care management visit with Dina Hobson, MSN, CRNP, ANP-BC, and the team, call Georgia-based VirtuaReal Health or schedule your virtual appointment online today.

What is transitional care management?

Transitional care management is the care you receive before, during, and after you change medical facilities or when you discharge from a hospital. 

The team at VirtuaReal Health ensures you receive all of the education and services you need to remain comfortable and avoid any possible health complications as you go through these major changes in your care plan. 

You might benefit from transitional care management as you move from:

• A hospital to a skilled nursing facility (SNF)
• A hospital to an assisted living facility
• A hospital to a nursing home
• A hospital to your home
• An inpatient rehab unit to your home
• An inpatient rehab unit to a skilled nursing facility (SNF)

You might also transition from an inpatient hospital or rehab unit to a lower level of care, which doesn’t require you to be at the facility every day but still may require ongoing contact with medical professionals. 

Telehealth at VirtuaReal Health makes these major transitions simpler and helps you adhere to a care plan with less supervision. 

What is the main goal of transitional care management?

The main objective of transitional care management at VirtuaReal Health is to prevent readmission into a hospital, rehab program, or other inpatient care. 

Going straight back home after your time in an inpatient facility without any support could make it harder to stay with your care plan, which can lead to health complications or a relapse, depending on your initial reasons for admission. 

For around 30 days after your discharge, the VirtuaReal Health team sees you regularly with video calls to check in on how you’re feeling and verify that you’re continuing with your treatment.

What does transitional care management entail?

Every 30-day transitional management program with VirtuaReal Health is unique. As a telehealth-only practice, VirtuaReal Health sees you with regular remote visits. You can log in on your phone, computer, or tablet and talk to the team from wherever you are. 

Your transitional management might involve:

• Remote patient monitoring of vital signs
• Medication management
• Daily therapy services, like physical therapy or respiratory therapy
• Personalized lifestyle advice
• Assistance with personal care

When you’re in a hospital or other inpatient facility, you’re often on a strict schedule with direct reminders to take your medication and engage in directly supervised care. Transitional management helps you develop and maintain a self-care plan as you get accustomed to a new routine at home or elsewhere.  

If you’re leaving a hospital or other inpatient facility soon and may need transitional care management, call VirtuaReal Health or schedule an appointment online today.