Transitional Care Program
For patients who are discharged from a hospital or post-acute care facility and are ready to transition back to their homes, SPG offers a Transitional Care program as a means to bridge the patient back to their own physician and reduce the chance for readmittance by ensuring proper post-care and follow-up care practices are followed.
The post-discharge period can be a vulnerable time for patients, and this outpatient program helps guide the transition to home with phone calls, home visits and coordination of services as needed.
Similar to a case management program, SPG’s care team will reach out via phone or in-person visit to ensure patients are following the recommended instructions for follow-up appointments or home care in order to lower any chance of adverse events that may cause unnecessary readmissions.
SPG’s physician-based model is built upon the collaboration with partnering facilities, specialists and any other ancillary provider, patients, and families to help patients get back on track with their healthcare needs.