Transitional Care Program

The Transitional Care Program by House Concierge MD LLC, serving the Greater Orlando area, is designed to provide seamless healthcare support to individuals transitioning from hospital to home. This program is crucial for those who have undergone surgery, treatment for acute illness, or any hospital stay that necessitates ongoing medical care and monitoring during recovery.

Delayed follow-up care and deviations from discharge instructions significantly elevate the risk of hospital readmissions, exerting pressure on both the healthcare system and the well-being of patients and their families.

An example of a nurse and a patient for the Transitional Care Program

House Concierge MD collaborates closely with hospitals, surgical and specialty practices, as well as directly with patients, to meticulously orchestrate transitional medical care prior to discharge. We then extend in-home follow-up care in Orlando and its neighboring counties immediately after patients leave the hospital.

Indicators for a Transitional Care Program

  • Recent discharge from a hospital or rehabilitation facility
  • Post-surgical recovery requiring follow-up care
  • Acute illness treatment necessitating ongoing medical support
  • Older adults 65 plus or those with chronic conditions facing difficulties post-hospitalization
  • Need for medication management and health monitoring post-discharge

The Need for Effective Transitional Care

Transitioning from hospital to home can be a vulnerable period for many patients, especially the elderly or those with chronic conditions. This phase often requires specialized care to prevent complications, manage medications, and ensure continuity of care. Without adequate support, patients are at risk of hospital readmission, often due to medication errors, inadequate follow-up, or the inability to manage post-discharge care plans.

Our Transitional Care Program (TCP) addresses these challenges by providing comprehensive support during this critical period. It aims to bridge the gap between hospital and home care, ensuring patients receive medical attention and guidance to recover safely and effectively in their homes.

Treatment Process

  • Initial Assessment: Evaluating the patient’s medical needs post-discharge.
  • Care Plan Development: Creating a personalized care plan that includes medication management, follow-up appointments, and any necessary home healthcare services.
  • Coordination of Services: Arranging for remote patient monitoring, mobile lab draws, mobile imaging, and pharmacy deliveries as needed.
  • Regular Health Monitoring: Continuous monitoring of the patient’s health status to prevent complications.
  • Ongoing Communication: Regular communication with the patient, family, and healthcare providers to ensure cohesive care.

The Transition Care Program (TCP) we offer is a proactive, house call-based approach to transition care, designed to navigate patients through the critical phases of recovery post-hospitalization or surgery. Our dedicated care teams liaise with medical facilities and patients before discharge to ensure a seamless transition. Following discharge, our first step is conducting an in-home visit to evaluate the patient’s health, alongside social and environmental considerations that may impact recovery. This direct insight allows our team, in partnership with the discharging facility and the primary care physician, to adapt the discharge plan to fit the unique needs of each patient or proceed as originally planned.

We meticulously implement or adjust care plans, monitoring patients with a frequency dictated by their risk level to forestall any discrepancies or deviations, promptly addressing any issues based on the patient’s reaction to treatment, virtually in real-time.

We ensure a coordinated continuum of care by facilitating a smooth transition back to the patient’s regular primary care physician at the end of the transitional period, should the patient wish. Our approach underscores our commitment to professional excellence and confidence in delivering superior transitional healthcare services.

Reducing Hospital Readmission

A key goal of our Transitional Care Program is to prevent hospital readmissions by providing thorough post-discharge care. Regular health monitoring and timely medical interventions can identify and address potential complications before they escalate. This proactive approach improves patient outcomes and enhances the overall recovery experience.

Additionally, educating patients and caregivers on managing health conditions at home is vital to our program. It empowers patients to participate actively in their recovery and health maintenance.

Enhanced Recovery and Long-Term Health

Patients enrolled in our Transitional Care Program can anticipate a more supported, less stressful recovery process. By receiving comprehensive care tailored to their needs, patients are more likely to recover successfully at home, reducing the risk of complications and hospital readmissions.

This program signifies a commitment to continuous, integrated care, providing patients with the support and resources they need to transition smoothly from hospital to home, ultimately leading to better long-term health outcomes.

Frequently Asked Questions

Q: Who is eligible for the Transitional Care Program?

A: The program is ideal for patients recently discharged from a hospital, rehabilitation facility, or ambulatory surgery center who need extra care during recovery; exclusions include incarcerated, hospice, and nursing home patients. Due to limited staffing, wound-vac and wound care will be considered on a case-by-case basis.

Q: How long does the Transitional Care Program last?

A: The duration varies based on individual needs, but it is typically designed for the critical weeks following hospital discharge; up to 30 days. Patients are then returned to the care of their regular doctor.

Q: Are services like mobile lab draws and pharmacy deliveries included?

A: Yes, our program includes a range of services like mobile lab draws, imaging, and pharmacy deliveries to support your recovery; these services may incur an extra fee.

Q: Can family members be involved in the care process?

A: Absolutely, we encourage family involvement and provide them with the necessary information and support.

Q: How does the program help prevent hospital readmission?

A: By providing comprehensive post-discharge care, regular monitoring, and addressing health issues promptly, we help reduce the likelihood of hospital readmissions.

Your Path to Recovery, Our Commitment to Care

House Concierge MD LLC is dedicated to ensuring a smooth and safe transition from hospital to home for patients in the Greater Orlando area. Our Transitional Care Program reflects our commitment to providing continuous, high-quality care tailored to each patient’s unique needs.

If you or a loved one is transitioning from hospital to home, consider House Concierge MD LLC’s Transitional Care Program. Contact us today to learn how we can support your recovery journey with personalized, comprehensive care right in the comfort of your home. Your health and seamless recovery are our top priorities.

Costs and Payment

For hospitals, medical facilities, specialty practices participating in the Transition Care Program, House Concierge MD will bill the participating hospital / entity based on agreed rates. In some cases the full cost of Transition Care Program may not be covered by the Hospital or Medical Facility and the patient will be billed the remaining portion.
No insurance. No problem. You can pay us directly and we accept all major credit cards.
Patients may also be eligible to submit a claim to their insurance plan.

Contact us to learn more information about our Transitional Care Program
Phone our Chief Care Coordinator: 689-444-5086 , 407-476-5936 or email

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House Concierge MD

Bringing Health to Your Doorstep


Call us today to schedule an appointment 689-444-5086

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