For patients who have medical and/or psychosocial conditions that continue to require a moderate or high level of medical decision making, traditional home health services just aren't enough.

Patients are extremely vulnerable after having an acute episode and the transition from a hospital or skilled nursing facility to home is one of the most overlooked aspects of many post-acute programs. MPAC's Transitional Care Program works in conjunction with traditional home health services to eliminate the potential gap by providing initial and on-going high-level medical care for the patient at home. 

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Care Model

Immediately following discharge an MPAC provider essentially serves as an interim primary care provider. In conjunction with home health services, MPAC's Transitional Care Program provides:

  • A structured checklist of critical activities designed to empower patients and/or their caregivers before and immediately following a discharge
  • On-going in-home face-to-face visits
  • Assessment and treatment regimen adherence and medication management
  • Training for medication self-management
  • Education about symptoms which indicate a medical condition is worsening and how to respond
  • A coordinated hand-off to a community primary care physician following the 30 day discharge period
  • Assistance establishing or re-establishing referrals and arranging needed community services
  • Assistance with scheduling any required follow-up visits with community providers and services

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