The Transition Plus Program aims to prevent hospital readmission and improve overall patient morbidity and mortality rates. ProCenture house physicians and extenders complete follow-ups with patients immediately, within 48-72 hours upon their discharge. We evaluate the patient’s hospital course, treatment, and reconcile their medications appropriately.


The largest contributing factor to hospital readmission and increased mortality and morbidity rates is due to 70 percent of patients confusion concerning their treatment plan following their hospital stay, particularly amongst the elderly and disabled population. Our clarification of treatment plans and attentiveness to patient care after a hospital discharge is effective in reducing such occurrences.


Our process to ensure a smooth transition from hospital to home begins with communicating with the patient’s hospital physicians, discharge team, and home health agencies to ensure all necessary materials, medications and resources are provided.


During our visit, extensive patient education is undertaken with both the individual and their caregivers to ensure they are kept informed about their medical conditions. Medication reconciliation and missing prescriptions are called-in in real-time during the visitation. Follow-up calls are provided to patients by members of our team to ensure the patient’s condition continues to improve. We also communicate with primary care providers to guarantee proper handover of patients and ongoing care. If a patient does not have a primary care provider and seeks to retain us as a primary care team, we make arrangements for specific physicians to assume care.


If you are a facility that seeks to improve your readmission rates and improve quality measures, contact our office to speak with a member of our post-hospital discharge team.