Transitional/Home Visit Services

At Optimum Care Partners, we are committed to ensuring a smooth transition from hospital to home, particularly for patients at high risk of readmission. Our goal is to provide comprehensive care that reduces hospital readmissions and enhances the overall quality of life for our patients.

High-Risk Patient Identification and Screening

Our process begins at the hospital. Optimum Care hospitalists identify patients who are considered high-risk for readmission based on their medical history and current health condition. Once identified, a referral is submitted to our team for further evaluation. Our dedicated care team then screens each patient and reaches out to ask for permission to conduct an at-home visit.

At-Home Visits for Personalized Care

Once the patient consents, our care team visits the patient’s home to perform a thorough assessment. These visits allow us to provide medical care in the comfort of the patient’s home and to address any post-hospitalization needs. We take the time to understand each patient’s unique circumstances, ensuring they receive the right support as they recover.

Complete Collaborative Care Model

We are proud to offer a Complete Collaborative Care Model, designed to bring together all necessary specialists, home health providers, and hospice services. Our approach ensures a personalized care plan is developed for each patient, involving the right professionals to meet their health needs. This model not only provides continuity of care but also ensures that every aspect of a patient’s health—both physical and mental—is considered.

Reducing Hospital Readmissions and Increasing Quality of Life

Our primary goal is to reduce hospital readmissions while improving each patient’s overall health and well-being. By coordinating care between healthcare providers, specialists, and the patient’s family, we create a seamless healthcare experience that prioritizes the patient’s needs and promotes recovery.