🌿 Transitional Care Plan

Five-week structured program | 60–90 minutes per visit | Eight total visits | $640 one-time payment (due at start of care)

The Transitional Care Plan supports clients moving between levels of care—after a hospital stay, skilled-nursing-facility rehabilitation, surgery, or acute illness. It provides coordinated, personalized nursing that ensures a safe and steady recovery in the comfort of home or a temporary residence such as a hotel or family home.

This plan follows a carefully phased 3-2-1 structure to ensure consistent support during the most critical transition period:

• Week 1: Three visits (60–90 min each)

• Week 2: Two visits (60–90 min each)

• Weeks 3–5: One visit per week (60–90 min each)

• Two tele-health check-ins (40 minutes max each, included at no additional charge)

Care includes a comprehensive assessment, medication review and reconciliation, pain management, vital-sign and wound monitoring, and education for both patients and families. Each client receives individualized attention to mobility, therapy coordination, and personalized goals that reduce the risk of hospital readmission.

Your nurse coordinates follow-up with providers and specialists, assists with community and in-home support—such as meal or housekeeping resources when needed—and provides ongoing monitoring to prevent complications, identify early signs of infection, and promote confidence and comfort throughout recovery