Transitional Care Management Specialist

What is transitional care management?

Transitional care management at Generations Family Practice helps you get the medical attention and treatment you need after leaving a hospital, psychiatric inpatient center, another inpatient center, or a nursing home. 

Transitional care ensures you have the tools to stay healthy while transitioning into a different environment or lifestyle. For example, it may combine physical rehabilitation, occupational therapy, and speech therapy to help you regain your independence after a hospital stay. We can coordinate the services you need with your primary care provider after a hospital stay.

Which transitional care management services are available?

At Generations Family Practice, the team provides and coordinates various transitional care management services, including:

Primary Care

Understanding your discharge plan of care, ensuring your medications work as intended, and investigating any complications related to a recent hospitalization are critical services to avoid readmission. Generations starts the process of hospital transition immediately after discharge, and we support our patients through both primary care, and the coordination of services, post discharge.

Physical rehabilitation

Physical rehabilitation combines stretches, strengthening exercises, and manual techniques, like acupuncture or massage, to enhance your mobility and encourage your body’s healing process. This type of transition care is particularly beneficial for people recovering from orthopedic surgery, like a joint replacement.

Medication management

The Generations Family Practice team reconciles all your medications from all your providers during your post discharge follow up visit to ensure you feel comfortable with your plan of care after undergoing surgery or being diagnosed with a chronic (ongoing) condition. We also provide osteopathic manipulation and joint injections, and have Select Physical Therapy on site to help with post surgical issues.

Chronic care management

If you have a chronic disease or another ongoing medical problem, Generations Family Practice providers help you manage the condition with a care manager to reduce unpleasant symptoms, the risk of complications, and help you reach your health goals.

Smoking cessation

If you struggle to quit smoking, Generations Family Practice offers highly effective smoking cessation programs and treatments to help you quit for good and reduce the risk of future health problems.

Occupational therapy

Occupational therapy helps you regain your independence. Specifically, it focuses on activities of daily living, like getting dressed, feeding yourself, and using the toilet. To assist you in these efforts, the team at Generations Family Practice can coordinate with your occupational or durable medical equipment provider. 

Speech therapy

If you experience a stroke or a traumatic brain injury, you might need speech therapy to regain your conversational skills. Speech therapy can help you regain skills you’ve lost and teach you new ways to communicate.

How long does transitional care management last?

The length of time transitional care management lasts depends on various factors, including your age, the duration of your inpatient or nursing home stay, and your general health. Your Generations Family Practice provider can develop a transitional care plan following a consultation, with a goal of returning you to your normal activities, and continuing your primary care. 

Transitional care is most important during the first 30 days post discharge, but the practice also offers comprehensive primary care services and chronic condition management you can take advantage of for a lifetime.

Am I a candidate for transitional care management?

Experienced medical providers determine if you’re a candidate for transitional care management. That said, if you’re preparing to undergo surgery, or you have a chronic illness that causes you to visit a hospital or another inpatient facility, you probably qualify. 

Following a review of your medical records and discussing your needs, the Generations Family Practice team develops a custom care plan.

To learn more about the benefits of transitional care management, make an appointment at Generations Family Practice by calling the office or clicking the online booking feature today.