Transitions Care

Current data indicates that 15% to 25% of individuals who are discharged from hospitals will be readmitted within 30 days or less and that many of these readmissions are preventable.. (1) A high quality transitions program has been proven to significantly reduce readmission rates. One study conducted at Baylor Medical Center at Garland (Texas) found a nurse-led transitional program reduced adjusted 30-day readmission rates by 48 percent. (2)

By Service Elite working closely with those individuals who have been recently discharged, we have been successful with transitioning them back home after a hospitalization and dramatically reducing avoidable readmissions through providing health education, support programs and help to access community based services. Service Elite’s High Quality Transition Care Services provides short-term Care Management to the elderly, frail and disabled individuals immediately following an in-patient stay to ensure a successful recovery at home.

Service Elite High Quality Transition Services – we listen to our clients to understand how we can best help to get them back into their normal routine as quick as possible. We want to help prevent problems before they arise because they could cause set-backs in recovery that can cause re-admission back into the hospital.


How We Help Our Clients

  • Understand discharge and/or doctor’s orders of care
  • Gain access to meals, transportation and any other support services you need
  • Get a Benefits Check Up (financial assistance qualification to varies programs)
  • Gain knowledge about medications
  • Get prescriptions filled and assist in organizing them
  • Secure appointments and help to get to them
  • Assist in service providers coordination
  • Understand and maximize health and long-term insurance benefits
  • Making sure the home is a healthy and safe place for recovery
  • Fully understand what is needed for self-care for healthy living
  • Have peace of mind of transition and to family members


We help ensure our clients get what they need, when they need it

at the best highest quality level possible...watching for what could fall between the gaps.


We use a powerful multi-faceted holistic program that works together:
All-inclusive Collaborative Team -  Your Transitions Care Team consists of nurses, social workers and health professionals who are committed to your care and recovery. They all work together on your behalf as your health coach and advocate ensuring you get what you need, when you need it, how you need it in the best quality standard possible.

Personalized Counseling -  Transition Care Coach meet with clients in the hospital or skilled nursing facility prior to discharge. They explain the discharge to follow at home. An in-home visit is conducted within 24 to72 hours of the discharge. Individuals are then monitored by the Transitions Coach and Transition Care Coordinators who maintain regular telephone contact for the duration of the transition period (up to 90 days), monitors progress and update the individual’s health record, doctors, and consented family members.

Comprehensive Home Visit & Care Plan - The Transition Care program provides expert coordinated transition planning, service delivery and monitoring through a Comprehensive Home Visit Schedule. On the first visit the Care Manager completes a survey which gives the Transition Care Team a better sense of the individual’s needs and current lifestyle and what interventions and monitoring that may be required to ensure successful recovery at home in which a comprehensive care plan is developed. The home visits are a vital part of the program to help ensure a successful transition after discharge that significantly increases the probability of a safe and healthy recovery at home.

Service Providers Monitoring -  The care plan includes both clinical and support service monitoring through regular telephonic outreach and the continual exchange of data and information with all the critical components of our client’s care. Pro-active communications with everyone that’s involved in our client’s caregiving further ensures a successful outcome.

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