Transitional Care
Leaving the hospital should not mean losing the thread of your care.
Transitional care helps reconnect the pieces after a hospitalization, skilled-nursing stay, emergency evaluation, or another major change in treatment. Alderon’s transitional-care model is designed to review what happened, reconcile medications, identify pending tests and follow-up needs, and help establish a clear plan for what comes next.
Alderon is preparing to open for patient care. Join the interest list for launch updates and enrollment information.
- Medication reconciliation
- Post-discharge follow-up
- Next-step coordination
Your transition plan
ReconnectedFor Healthcare Professionals
Coordinating the next step for a patient?
Alderon’s professional referral pathway is designed for case managers, discharge planners, social workers, care coordinators, post-acute teams, and other healthcare professionals exploring transitional follow-up or ongoing primary-care access for appropriate adults.
Professional referral information is kept separate from the patient-facing care experience so that discharge teams can quickly review fit, scope, and the intended secure handoff process.
Transitional Care at Alderon
The discharge paperwork is not the end of the care plan.
Transitional care creates a deliberate bridge between what happened in the hospital or another care setting and what the patient needs after returning to the community. That means identifying medication changes, unanswered questions, pending results, follow-up appointments, and symptoms that need attention.
Patient resource: Medicare provides a discharge planning checklist to help patients and caregivers organize medications, follow-up appointments, warning signs, and questions before leaving a hospital or other care setting. (opens in a new tab).
Reconstruct what happened
Review discharge documentation, diagnoses, procedures, consultant recommendations, available test results, and the reason treatment changed.
Reconcile medications
Compare the pre-admission medication list with the discharge plan and clarify medications that were started, stopped, changed, duplicated, or left unclear.
Identify unfinished work
Determine whether laboratory results, imaging, specialist recommendations, procedures, referrals, or additional appointments are still pending.
Follow recovery
Reassess symptoms, medication tolerance, function, home needs, warning signs, and whether the recovery plan is progressing as expected.
Transitional Care May Include
Bring the discharge plan back into one understandable picture.
The needs after discharge vary widely. The goal is to identify the items most likely to affect recovery, medication safety, follow-up, and the patient’s ability to manage care at home.
Medication reconciliation
Compare old and new medication lists, clarify dose changes, remove duplication, review treatment indications, and identify potential safety concerns.
Pending tests & diagnostic follow-up
Identify laboratory results, cultures, pathology, imaging, or diagnostic workups that still require review or additional action.
Referral & appointment coordination
Clarify which specialists, procedures, rehabilitation services, or other follow-up appointments were recommended and whether they have been arranged.
Recovery assessment
Review pain, breathing, appetite, hydration, mobility, wound concerns, medication effects, or other symptoms relevant to the recent illness or treatment.
Equipment & support needs
Identify issues involving home health, durable medical equipment, rehabilitation, caregiver support, or other resources that may affect a safe recovery.
Return to longitudinal care
Reconnect the recent hospitalization or acute illness with chronic conditions, prevention, medications, and the patient’s ongoing primary-care plan.
After Discharge
The first days at home can reveal problems that were not obvious before discharge.
Medication confusion, worsening symptoms, missing prescriptions, difficulty arranging follow-up, new functional limitations, and uncertainty about discharge instructions can emerge after the patient is already home.
A timely transitional-care review creates an opportunity to identify these problems while they may still be easier to address.
A post-discharge review may address
- Discharge diagnoses and treatment course
- Medication changes and access
- New or worsening symptoms
- Pending test results
- Specialist and procedure follow-up
- Home-care and recovery needs
Telehealth-First Transitional Care
Much of the coordination can happen without another trip across town.
Transitional care is often well suited to telehealth because much of the work involves reviewing records, medications, symptoms, discharge instructions, pending testing, and follow-up needs.
Local examination, laboratory testing, imaging, wound evaluation, rehabilitation, home-health services, or specialty care can be added when the clinical situation requires them.
Follow-up may use:
- Hospital and discharge records
- Medication lists and pharmacy information
- Home vital signs when clinically useful
- Local laboratory and imaging results
- Specialist recommendations
- Connected home-health data when appropriate
Medicare Transitional Care Management
Formal Medicare TCM has specific eligibility and billing requirements.
Transitional care is broader than a billing code.
Alderon’s transitional-care model may include clinically appropriate post-discharge follow-up even when a visit does not meet the requirements for formal Medicare Transitional Care Management billing. Medicare TCM coverage depends on a qualifying transition, timing, required follow-up, provider participation, patient eligibility, and applicable Medicare rules. Alderon will not represent a service as covered Medicare TCM unless the relevant requirements are met.
When Recovery Is Not Going as Expected
Post-discharge symptoms can still become emergencies.
Do not wait for a routine follow-up when serious symptoms develop.
New or worsening chest pain, severe difficulty breathing, stroke symptoms, loss of consciousness, uncontrolled bleeding, severe abdominal pain, significant confusion, severe weakness, rapidly worsening infection, serious medication reaction, or another potentially life- threatening condition requires prompt evaluation. Call 911 or seek emergency care when appropriate.
Related Care
The transition ends when ongoing care is reconnected.
Frequently Asked Questions
Transitional care, explained.
What is transitional care?
Transitional care helps patients move safely between healthcare settings or back into the community by reviewing what happened, reconciling medications, coordinating follow-up, and addressing unresolved needs after the transition.
Do I need my hospital records before the visit?
The more discharge information available, the better. Helpful records may include the discharge summary, medication list, test results, consultant recommendations, follow-up instructions, and information about pending studies.
Why is medication reconciliation important?
Hospitalizations often lead to medications being added, stopped, substituted, or changed. Comparing the pre-hospital and discharge medication lists can identify duplication, conflicting instructions, missing medications, or other safety concerns.
Can transitional care happen through telehealth?
Often, yes. Record review, medication reconciliation, symptom assessment, care coordination, and follow-up planning can frequently occur virtually. Some patients still need local examination, testing, imaging, procedures, rehabilitation, or specialty care.
I am a case manager or discharge planner. How do I refer a patient?
Visit Alderon’s Case Managers & Discharge Planners page for referral-fit information, scope, clinical boundaries, and the professional workflow. Do not submit patient-specific clinical information through the public website. Alderon will identify the secure handoff process for patient information.
Is every post-hospital visit billed as Medicare TCM?
No. Formal Medicare Transitional Care Management has specific eligibility, timing, service, and billing requirements. A clinically useful post-discharge visit may still occur even when those formal requirements do not apply.
What if I get worse after I come home?
Follow the discharge and return precautions you were given. New or worsening symptoms may require earlier follow-up, urgent in-person evaluation, or emergency care depending on severity.
Transitional Care
Bring the pieces back together after discharge.
Join the interest list for launch updates and information about post-discharge follow-up, medication reconciliation, and reconnecting recent acute care with ongoing care.