Transitional Care & Support

Managing your care at home after a hospital or skilled nursing facility (SNF) stay can be confusing and difficult.

At Southwest Medical Centers we offer care coordination (also called transitional care management) if you need assistance organizing your care after leaving a facility.As your primary care provider, we automatically provide care coordination, or you can request services by asking that your hospital or SNF notify your PCP about your discharge home.

You should receive an in-person visit from your provider within 7 or 14 days of your return home, depending on the complexity of your condition. We provider offer the following services, as necessary:

• Contact you within two days of leaving the hospital or SNF
• Work with your other health care providers to provide education and other services to help you transition back to living at home
• Review your medications and any changes that have been made.
• We review the need for follow-up visits and help you schedule them
• Identify medical needs you have and arrange referrals to follow-up care and other community resources