At Transitional Care - Westwood, we are an integrated team of medical, behavioral and social work professionals who work together to support recently discharged patients in their efforts to regain their health and wellness. Research shows that patients who have been recently discharged from the hospital demonstrate much better long term outcomes if they have a follow-up visit with a physician within 14 days. We can provide that follow-up care, as well as other services, for patients with no insurance, patients who do not have a primary care provider and patients who can not see their regular physician within that period.
We assist patients through:
- Hospital discharge follow-up visits
- Medication assistance
- Referrals: specialty and community services
- Behavioral health counseling
The post-hospital follow up visit presents a critical opportunity to address the conditions that caused the hospitalization and to prepare the patient and their caregivers for self-care activities.