Transitional care after a hospital stay
The two weeks after discharge are the most dangerous stretch in a chronic illness. Discharge paperwork changed your medications, nobody explained the changes, and the follow up appointment is three weeks out.
A visit within 48 to 72 hours
We aim to be in your home within two to three days of discharge. The visit reconciles the discharge medication list against what is physically in the house, confirms you can get and afford the new prescriptions, checks the surgical site or the swelling or the breathing that put you in the hospital, and makes sure the home health agency actually showed up.
Talking to the hospital
We request the discharge summary directly and read it before we arrive. If something in it does not match what happened, we call the discharging service rather than asking you to relay it.
The following weeks
Transitional care continues with a second visit at around two weeks and nurse line check-ins in between. When the risk period passes, you move onto a normal primary care schedule with us or return to your previous doctor, whichever you prefer.
Where we provide this
Morris County
Boonton, Chatham, Chester, Denville, Dover and 14 more towns.
Essex County
Belleville, Bloomfield, Caldwell, Cedar Grove, Essex Fells and 13 more towns.
Union County
Berkeley Heights, Clark, Cranford, Elizabeth, Fanwood and 12 more towns.
Somerset County
Basking Ridge, Bernardsville, Bound Brook, Branchburg, Bridgewater and 12 more towns.
Passaic County
Bloomingdale, Clifton, Haledon, Hawthorne, Little Falls and 11 more towns.
Bergen County
Bergenfield, Cliffside Park, Englewood, Fair Lawn, Fort Lee and 13 more towns.
Questions about post-hospital transitional care
Can you arrange this before discharge?
Yes, and that is the ideal. Ask the hospital case manager to call us, or call us yourself from the hospital room.
What if I already have a primary care doctor?
We can do transitional care as a one time service and send the full note to your regular doctor.
Conditions we manage with this
Other care we bring to the home
Primary Care House Calls
A full primary care visit in your living room, exam and all.
Read moreChronic Disease Management
Steady follow up for diabetes, heart failure, COPD, hypertension and kidney disease.
Read moreMedicare Annual Wellness Visits
The yearly Medicare wellness visit, done at your kitchen table.
Read moreGeriatric and Dementia Care
Calm, unhurried care for older adults, including patients with dementia.
Read moreReady for a visit at home?
Call and speak with a real person. We will confirm your insurance, find a time and come to you.
973-607-4911 Call now