Most successful transitional care programs have been led by nurses who make home visits and sometimes follow-up telephone calls. Under this program, patients get an enhanced transitional care office visit right after their discharge from a hospital or SNF. One other thought (mine, not theirs): Much of this kind of transitional care does not need to be provided by an MD, and perhaps should not be. These professionals may be based in a physician practice but the docs themselves would not be doing the transitional care work. We know that transitional care is an important part of successful discharges from hospitals and nursing homes.

Source: Forbes September 21, 2018 15:12 UTC