Transitional Care Management

For a patient who has been hospitalized or rehabilitating for many days or weeks, transitioning from a hospital or skilled nursing facility back home can be stressful and sometimes difficult. A transitional care home visit by a Nurse Practitioner can help smooth the way and keep patients on the track to getting better. This type of clinical home visit is made within two weeks of discharge.

Home visits by a Nurse Practitioner (NP) are important to your overall continuity of care and will enable your transition to a home setting go more smoothly. The NP will have direct access to medical records from the facility you recently discharged, enabling a more concise discussion about your current status and situation with the provider team to identify clinical concerns or changes in your condition that may have occurred since your return home. This continuity of care greatly enhances the safe transition back to your home.

The Nurse Practitioner performing your home visit is an experienced clinician. They can write prescriptions, refills, and/or lab orders as necessary, which is very different than what Home Health services can offer. Nurse Practitioners work alongside Home Health services to supplement care. Home Health is provided by a separate certified agency where nurses (RNs and LPNs), and sometimes therapists (PT, OT, ST) and social workers come to your home intermittently over a period of weeks to provide nursing therapy and educational instruction regarding your condition. Palliative Community Resource Nurse Practitioners are not affiliated with your home health services.

Like a physician or Nurse Practitioner office visit, you may be responsible for a copay of approximately $35, depending on your insurance.

Preventing Readmissions

The United States has a hospital re-admission problem. About 1 out of 5 patients admitted to hospitals in America are re-admitted within 30 days. Those re-admissions are expensive. The average cost of 1 hospitalization in the U.S. is $15,000 but the cost of hospitalization plus 1 re-admission is $33,000. In other words, re-admissions are more costly than the initial admission.

Medicare’s solution: fine hospitals with higher re-admission rates. In 2017, Medicare penalized 2,597 hospitals for readmissions over the national average. (

Patients adherence after discharge is a concern. With a transitional care visit by a Nurse Practitioner, an additional layer of assessment, support and instruction can be can help ensure patients have the help and encouragement they need following hospital and skilled nursing facility discharge.

The specialized oversight and care that Transitional Care Management offered by Nurse Practitioners helps patients with life limiting illnesses stay at home and out of the hospital.

Transitional Care Management Frequently Asked Questions

Palliative Care FAQs

Palliative Care is specialized medical care for people living with a serious illness. It is focused on managing symptoms – whatever the diagnosis. Improved quality of life is the goal.

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