Transitional Care 2017-08-12T19:05:36+00:00

From the Hospital to your Home

The Primary Care of Central Florida Hospital to Home Transition Care Program has been established to reduce the rate of preventable re-hospitalizations for the first 30 days post discharge by highly trained Providers delivering quality clinical services via standardized care protocols.

The program aims to help patients and their family members better understand the disease state and develop proper responses to changes in condition. It also enables the patient to establish a relationship with a regular Provider for ongoing care.

The Primary Care of Central Florida Transition Care Program has been established for patients who have had a number of hospitalizations over the course of a few months for the same diagnosis and or for patients who utilize the emergency room on a frequent basis and typically do not have their own primary care physician.

The targeted disease states for hospital to home patient coverage and participation:

  • Congestive Heart Failure (CHF)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Diabetes
  • Disease processes that tend to fluctuate in nature leading to exacerbations and hospital admissions.

Primary Care of Central Florida works with hospital discharge planners and health plans to coordinate hospital to home program participation, discharge and care for all primary and in-home healthcare services a patient may require. Coordination includes: physician house calls, skilled nursing, physical therapy, home healthcare, durable medical equipment and laboratory and diagnostic testing. Additionally, education and support is provided to help patients stay healthy and stay at home.

Transitional Care Services Provided by Primary Care of Central Florida

Social workers or family members, to schedule transitional care please call 321-235-0692

For program education and presentations contact Yolanda Covey.

  • Tel.       407-902-9536
  • E-mail  y.covey@homephysiciansgroup.com

Phone: 407-930-4845   Fax: 407-985-3592    www.pc-cfl.com