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Transitional Care

What is transitional care?

The term “transitional care” refers to a range of services designed to promote the safe and timely continuity of care for patients as they move between care settings. High-quality transitional care is especially critical for older adults with multiple chronic conditions and complex, multi-specialty care plans, who require continuity of care as they move frequently between care settings.


The National Institutes of Health reports that suboptimal “handoffs” of these older adults and their caregivers from hospital to home have been linked to adverse events, low satisfaction, and high rehospitalization rates. Transition Care Management (TCM) improves patients’ quality of life and helps reduce hospital readmissions.


Providers who round at a hospitals, skilled nursing facilities & rehab hospitals  with especially vulnerable geriatrics patients and their family members need assistance in discharge planning, transitional care, and in home care to ensure the success of patients who have returned to their home environment. 

Why is transitional care important?

Transitional care allows for patients to return home in a safe manner because of the continuity in care. Athena Specialty Group will assist patients including in home visits and coordination of home health services until patients are safely able to return to their primary care provider. If a patient does not have primary care provider, Athena Speciality Group will provide a referral for primary care to ensure successful outcomes.