Transitional care follows one of four options:
- The patient is sent out to a long-term sub-acute setting which is one level below a hospital setting.
- The patient is sent to a skilled nursing facility (SNF) and eventually discharged home from there or to another setting that will maintain the safety of the patient.
- The patient is sent home with close follow-up from home health nurses, home physical therapists, or a home follow-up through a visit or phone call from a designated nurse practitioner. They are also seen by one of the hospitalists in the post-discharge clinic where follow-up is arranged with the primary-care physician and any specialists needed.
- The patient is sent home with follow-up arranged with their primary-care physician, any specialists needed, and any potential high-risk management clinics that the patient may benefit from. Examples of these clinics include: Coumadin clinics, a COPD clinic, a CHF clinic, a Diabetes clinic, etc.