Transitions of Care
Seamless Support When You Need It Most
Bridging the gap between healthcare settings
What Are Care Transitions?
"Understanding Care Transitions"
Care transitions occur whenever you move between healthcare settings—from hospital to home rehabilitation to outpatient care or between different providers. These transitions are critical moments when miscommunication can lead to medication errors missed follow-ups or readmissions.
Southeast Medical Group's Transitions of Care program ensures nothing falls through the cracks during these vulnerable times. Our dedicated team works to make your transition as smooth and safe as possible.
COMPREHENSIVE SUPPORT
Our Transitions Services
What We Provide
Hospital Discharge Support
- Medication reconciliation and education
- Follow-up appointment scheduling
- Care plan clarification
- Home safety assessment referrals
- DME coordination
Post-Discharge Follow-Up
- 48-72 hour phone call after discharge
- Medication adherence support
- Symptom monitoring
- Question answering
- Connection to resources
Care Coordination
- Communication with all providers
- Medical record transfers
- Specialist referral assistance
- Home health coordination
- Therapy services arrangement
Why Transitions Matter
The Difference We Make
| Without Support | With Transitions Support |
|---|---|
| 20% readmission rate | 14% readmission rate |
| Medication errors common | Medications reconciled |
| Confusion about care plan | Clear understanding |
| Missed follow-ups | All appointments scheduled |
| Feel alone and worried | 24/7 support available |
1 in 5 Medicare patients are readmitted within 30 days. Proper transitions reduce readmissions by up to 30%.
Don't Navigate Transitions Alone
Who Needs Transitions Support?
Expert Support Every Step
Transitions support is especially important for:
- Recent hospital or ER discharges
- Patients with multiple chronic conditions
- Those with complex medication regimens
- Limited family support
- Frequent healthcare utilization
- Post-surgical patients
No Cost Service: Transitions of Care support is provided at no charge as part of our commitment to comprehensive patient care.
Available 24/7: Our team is ready to help whenever transitions occur.
