Delayed follow-up care and deviations from discharge orders increase the likelihood of being readmitted to the hospital. Re-admissions place stress on the health care system, patients and their families. We work with hospitals and patients, prior to discharge to plan transitional medical care, and then provide in-home follow up care immediately following discharge in Wichita Falls and surrounding areas.

Our Transitional Care Management provides a hands-on, house call model of transition care to manage patients through critical recovery gates after hospitalization and/or surgery. Our care teams work with discharging facilities and patients prior to discharge to plan transitional medical care. Upon discharge, we will immediately perform a follow-up visit in the patient’s home to assess the patient’s condition, as well as social and environmental factors that can affect recovery.  Insight gained from a house call follow-up visit helps our care team, in coordination with the discharging facility (and primary care physician), determine if discharge care plans need to be modified based on the patient’s individual post-discharge circumstances, or should be implemented as initially designed.

We work with the patient’s primary care physicians to ensure coordination of care and a smooth hand-off at the end of the transition period.