Transition Management

transitionalcareCare at Home’s Transition Management program treats patients who are at risk of readmission following discharge from hospital or skilled nursing facility. We provide focused programs for patients who have multiple clinical risk factors to reduce the probability of re-hospitalization.

Our clinical care team applies evidenced-based programs to ensure demonstrated improvements in patient outcomes. These augmented solutions successfully transition patients from hospital to home.

Care at Home’s propriety care programs include:

  • Smooth rapid transition from hospital or skilled nursing facility to home
  • Personal clinical case manager to coordinate patient care
  • State-of-the-art electronic medical records to enable seamless communication among hospitals, physicians, health plans and the patient’s Care at Home team
  • Customized medication reports for patients and their physicians to optimize administration of medications
  • Constant care coordination and communication with patient’s physicians
  • Patient involvement, education, goal-setting and monitoring to ensure ongoing patient improvement
  • Custom written self-care program upon discharge from Care at Home services

Care at Home is redefining the care continuum through improved coordination between all phases of care. All our professional caregivers have undergone comprehensive security and health screenings and receive frequent specialized training on ensure patients receive the best evidence-based care outcomes.


Medicare Certified State Licensed Home Health Agency
Private Insurance and Worker’s Compensation