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Transitional Care Program
Alegis Care, a division of Home Physicians, Transitional Care Program has been established to reduce the rate of preventable re-hospitalizations for the first 30 days post discharge by highly trained providers delivering quality clinical services via a standardized care protocol.
This program aims to help patients and their family members better understand the disease state and develop proper responses to changes in condition. It also enables the patient to establish a relationship with a regular provider for ongoing care.
Our Transitional Care Program has been established for patients who have had a number of hospitalizations over the course of a few months for the same diagnosis and or for patients who utilize the emergency room on a frequent basis and typically do not have their own primary care physician.
The targeted disease states for patient coverage and participation:
- Congestive Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- Diabetes
- Disease processes that tend to fluctuate in nature leading to exacerbations and hospital admissions.
Alegis Care works with hospital discharge planners and health plans to coordinate program participation, discharge and care for all primary and in-home healthcare services a patient may require. Coordination includes: physician house calls, skilled nursing, physical therapy, home healthcare, durable medical equipment and laboratory and diagnostic testing. Additionally, education and support is provided to help patients stay healthy and stay at home.