Transitional Care

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What is Transitional Care?

Angelic Health’s Transitional Care team provides patients with a smooth transition from hospital or rehabilitation facility to home. Our trained staff, which include an Advance Practice Nurse (APN), Registered Nurse (RN), and social worker, collaborate with the facility and community providers to ensure that the move back home is seamless.

Too often patients with chronic or serious conditions move from one healthcare setting to the next and experience frequent changes to their care plan, medication regimen, or treatments and miss out on sufficient communication to manage their own care at home.

Angelic Transitional Care coordinates the continuity of care during the transfer from healthcare setting to home to avoid mishaps with medications and treatments, ensuring patients are home safely and understand how to care for themselves effectively. These services focus on ensuring continuity of care, safety, and avoiding preventable re-hospitalizations.

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Angelic Health Transitional Care

Who qualifies

Anyone transitioning to home from a stay in the hospital or rehabilitation facility qualifies for Transitional Care. Patients with lengthy stays away from home, or chronic conditions benefit the most from this program.

How is transitional care paid?

Transitional Care is covered by Medicare, Medicaid, and most insurance plans. Co-pays may apply.

How does it work?

Prior to discharge the care team will meet the patient in the facility to discuss transition to home. After discharge a Registered Nurse or social worker will contact the patient by phone and the APN will visit patient at home. If additional visits are needed, we will work with the patient and his or her physician to ensure that needs are met. If further care is required to manage a symptom related to a serious or chronic condition, the patient may be eligible for Angelic Health Palliative Care program which will work with patient and physician to resolve those issues over a longer period of time.

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We provide clinical, social, spiritual, emotional and physical care to those experiencing a life-altering or terminal diagnosis. Patients are cared for wherever they call home - private residence, nursing care facility, assisted living, or other facility.

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