Transitional care is a service offered by St. Tammany Health system to ensure a smooth transition from your hospital stay to your regular home life.
When you are referred to transitional care, you will receive a phone call within 48hours of your discharge from the hospital. At that time your care team will coordinate home visits with a St. Tammany Nurse Practitioner and Registered Nurse.
These care team members will physically assess you in your home, review plan of care instructions, reconcile your medication regimen, and intervene with any issues or concerns you may have after discharge.
Most importantly, your transitional care team will be available for you as a safety net. You are encouraged to call your transitional care team with the promise of care management, effective communication with your usual care providers, and an empathetic ear on the other line.
Why you may benefit from transitional care:
Being hospitalized is stressful, and the return home can be just as taxing. When you leave the hospital, you will often be discharged with a new plan of care, new medications and a new specialty provider to follow up with.
Transitional care is available to help you navigate these changes and lessen the stress that accompanies a recent hospital stay.
Services offered
- Physical exam with our providers and nursing staff in your home for your convenience.
- Medication review to ensure appropriate plan of care.
- Medication refill as needed.
- Treatment of acute and chronic conditions with expedited availability.
- Ordering of diagnostic tests as needed.
- Ordering and referring to home health, physical therapy, occupational therapy or other specialty providers.
- Coordination of care, communication with your primary and specialty providers.
- Advanced care planning.
- Remote monitoring with daily vital signs reviewed by transitional care staff.