Transition Care Management

The transition program is designed to provide a unique form of managed care for 30 days after a patient is discharged from a hospital or another facility where he or she has been receiving skilled nursing care. The Transitions Program’s services include:

  1. Visiting the patient at home within 48 hours of discharge
  2. Coordinating a follow-up visit with the primary care physician within a week of discharge
  3. Doing home visits to ensure proper implementation
  4. Ongoing monitoring to ensure compliance with doctor’s appointments
  5. Ensuring that the patient follows his/her medication regimen as prescribed

Note: At the end of the 30-day cycle, an assessment is done to analyze whether or not the patient should be transferred to long term care management.

Long Term Care Management

In addition to providing short term care, Village Care also provides long-term care management services to help patients manage medical, legal, and financial issues which includes but not limited to:

  1. Professional oversight, planning, coordination and implementation of care plans
  2. Routine home visits to ensure all doctor’s orders are followed
  3. Managing and monitoring of all medications and home safety
  4. Support at doctor’s appointments and coordination of care among all physicians and other care providers
  5. Assistance in managing finances, accessing insurance benefits and identifying helpful community resources
  6. Notifying families of problems that may arise

Ongoing Support

Our professionals are devoted individuals who will work with you in a proactive fashion. They will listen to your needs and will find solutions according to those needs. Through home visits or by phone, you will be assigned to a Care Manager who will work with you in a one-on-one basis.

The ongoing support will be, but not limited to:

  • Coordinating your doctors’ appointments
  • Managing and monitoring your medication regimen
  • Helping you understand your medical bills
  • Making sure your home environment is a safe place to live
  • Helping you with transportation and other daily activities
  • Following up with your doctor’s recommendations

Next Steps...

Requesting a quote? Seeking employment? Click on our "Call to Action" link to let us know what's in your mind.