TRANSITIONAL CARE

Helping Patients Recover Safely After Hospital Discharge

Dvora Healthcare provides physician-led Transitional Care services throughout Salt Lake County, helping patients navigate the critical days and weeks following hospitalization, rehabilitation, or skilled nursing stays.

Request Care

WHAT IS TRANSITIONAL CARE?

Transitional Care Management (TCM) helps patients safely transition from a hospital, rehabilitation facility, skilled nursing facility, or other healthcare setting back to their home. The period immediately following discharge is often one of the highest-risk times for medication errors, complications, emergency room visits, and hospital readmissions.

Dvora Healthcare works closely with patients, families, hospitals, specialists, and caregivers to ensure care remains coordinated after discharge. Our goal is to identify concerns early, improve communication between providers, and support a safe recovery at home.

By providing physician-led follow-up and care coordination, Transitional Care helps patients recover with greater confidence while reducing avoidable complications.

WHO BENEFITS FROM TRANSITIONAL CARE?

  • Recently Hospitalized Patients

    • Individuals returning home after an inpatient hospital stay.

  • Post-Surgical Patients

    • Patients recovering after orthopedic, cardiac, abdominal, or other major procedures.

  • Skilled Nursing and Rehabilitation Discharges

    • Individuals transitioning home after rehabilitation or skilled nursing care.

  • Patients with Multiple Chronic Conditions

    • Those who require close monitoring following discharge.

  • Families Managing Complex Care Needs

    • Caregivers who need support navigating medications, appointments, and follow-up care.

WHAT IS INCLUDED?

  • Post-Discharge Follow-Up

    • Timely physician-led follow-up after discharge to review recovery progress and address concerns.

  • Medication Reconciliation

    • Reviewing discharge medications to identify discrepancies, reduce risks, and improve safety.

  • Care Coordination

    • Communication with specialists, hospitals, rehabilitation facilities, caregivers, and family members.

  • Treatment Plan Review

    • Ensuring patients understand discharge instructions and ongoing care recommendations.

  • Symptom Monitoring

    • Identifying complications early and intervening before problems become emergencies.

  • Specialist Follow-Up Coordination

    • Helping ensure follow-up appointments and testing occur as recommended.

COMMON TRANSITIONS WE SUPPORT

  • Hospital to Home

  • Skilled Nursing Facility to Home

  • Rehabilitation Facility to Home

  • Hospital to Assisted Living

  • Hospital to Memory Care

  • Post-Surgical Recovery at Home

  • Complex Medical Discharges

  • Cardiac Recovery

  • Pulmonary Recovery

  • Neurological Recovery

WHY TRANSITIONAL CARE MATTERS

The weeks immediately following a hospital discharge are among the most vulnerable periods in a patient's healthcare journey.

Many patients leave the hospital with:

  • New medications

  • Multiple follow-up appointments

  • Complex treatment plans

  • New diagnoses

  • Questions about recovery

Without proper support, these challenges can lead to emergency room visits, complications, and preventable hospital readmissions.

Dvora Healthcare helps patients and families navigate these transitions with physician-led oversight, coordinated communication, and ongoing support throughout recovery.

WHY CHOOSE DVORA FOR TRANSITIONAL CARE?

  • Physician-Led Oversight

    • Recovery plans guided by experienced medical professionals.

  • Improved Communication

    • Coordination between hospitals, specialists, caregivers, and families.

  • Care Delivered at Home

    • Follow-up care where patients feel most comfortable.

  • Readmission Prevention

    • Proactive support designed to reduce unnecessary hospital returns.

  • Personalized Recovery Plans

    • Every transition is unique and requires individualized support.

SERVING SALT LAKE COUNTY

Dvora Healthcare proudly serves patients throughout Salt Lake County, Utah.

Our providers regularly care for patients in:

  • Salt Lake City

  • Sandy

  • Draper

  • South Jordan

  • West Jordan

  • Murray

  • Holladay

  • Cottonwood Heights

  • Millcreek

  • Taylorsville

  • Midvale

  • Riverton

  • Herriman

  • and many other cities throughout Salt Lake County.

Our team works with patients returning home from hospitals, rehabilitation facilities, skilled nursing facilities, assisted living communities, and other healthcare settings across Salt Lake County.

FREQUENTLY ASKED QUESTIONS

  • Transitional Care Management is a healthcare service designed to support patients after discharge from a hospital, rehabilitation facility, or skilled nursing facility. The goal is to improve recovery, coordinate care, and reduce hospital readmissions.

  • The first few days following discharge are often the highest-risk period for complications. Early follow-up helps identify concerns quickly and improve recovery outcomes.

  • Yes. Studies have shown that coordinated follow-up care, medication review, and ongoing communication can help reduce avoidable hospital readmissions.

  • Patients recently discharged from a hospital, rehabilitation center, or skilled nursing facility may benefit from Transitional Care services.

  • Yes. We work closely with specialists, hospitals, therapists, rehabilitation providers, and caregivers to ensure continuity of care.

  • Medication reconciliation involves reviewing discharge medications to ensure they are accurate, appropriate, and clearly understood by the patient and caregivers.

  • Absolutely. Family involvement often improves communication, care coordination, and recovery outcomes.

  • Yes. Transitional Care services can be provided in homes, assisted living communities, memory care settings, and other residential environments.

  • Dvora Healthcare currently provides Transitional Care services throughout Salt Lake County, Utah.

Recovering After a Hospital Stay?

Dvora Healthcare helps patients safely transition home with physician-led care, coordinated communication, and personalized recovery support.

Contact Dvora Today!