Transitions of Care Services
Transitions of Care Services are available for patients who are at a high risk of rehospitalization. Home Health VNA clinicians collaborate closely with the physician, facility staff, and other community providers to ensure that a patient has the services and/or support to return and remain safely at home, in particular during the first 30 days after hospitalization. The primary focus is on symptom management, medication reconciliation, securing necessary supports, teaching, and self-management.
