Transitions of Care Services

Transitions of Care Services are available to patients who may need additional services and support after a recent hospitalization or treatment at a rehabilitation facility. Home Health VNA clinicians collaborate closely with the hospital or facility physicians and case managers, and with other community-based service providers, to ensure that patients have the services and/or support they need to return home and remain safe, in particular during the first 30 days after a hospitalization. The primary focus is on pain and/or symptom management, reconciling medications, securing support services and teaching self-management.