Our Transition Care Approach
Transition care management is especially important for seniors recovering from hip or knee replacement surgery, stroke or cardiac events, pneumonia or other acute respiratory illness, falls with significant injury, and major surgery requiring extended recovery. Our team has experience coordinating with all major Tacoma-area hospitals and rehabilitation centers, including St. Joseph Medical Center and MultiCare Tacoma General.
Who Benefits from Transition Care
We work with discharge planners, hospital social workers, and rehabilitation teams to ensure nothing falls through the cracks. Services include pre-admission coordination with hospital or rehab facility, medical equipment setup and room preparation before arrival, medication reconciliation and pharmacy coordination, physician follow-up appointment scheduling, detailed handoff communication with the outgoing care team, caregiver orientation to the resident’s specific needs and routines, family communication throughout the transition, and close monitoring during the first 30 days to prevent readmission.
