Care Coordination & Transitional Care

Care Coordination is a person-centered approach to managing healthcare and support services, ensuring that individuals receive the appropriate care at the right time. It involves collaboration between healthcare providers, social workers, and community resources to develop and implement a comprehensive care plan that meets the individual's medical, behavioral, and social needs. Care coordination helps improve health outcomes, enhance quality of life, and prevent unnecessary hospitalizations or institutional placements.

Transitional Care Services focus on supporting individuals as they move between different healthcare settings, such as from a hospital or nursing facility to their home or a community-based setting. These services aim to ensure a smooth, safe, and timely transition by providing care planning, medication management, follow-up care, and access to necessary support services. Transitional care helps reduce hospital readmissions, improve recovery, and promote long-term stability.