Happy senior woman and caregiver sharing coffee after transitioning to a home.
Caregiver feeding a senior woman as part of a transitional care management plan.
ElderTree transitional care management
Senior woman getting support from a transitional caregiver over coffee and cake
ElderTree transitions
Man in a wheelchair reading outside a nursing home with support from a care manager.

Smooth Transitions, Continuity of Care

Moving from the hospital to home or a rehab facility can be one of the most vulnerable times for individuals and their families. Without proper coordination, important details like follow-up care, medication changes, and instructions from physicians may overlooked — leading to confusion, setbacks, or even hospital readmissions. ElderTree’s transitional care management ensures every step of the process is planned, communicated, and followed through with care.

We work directly with hospital discharge planners, rehabilitation centers, and healthcare providers across Northern Virginia to create a detailed transition plan that prioritizes health, safety, and comfort. From coordinating transportation to scheduling follow-up appointments and ensuring communication,  ElderTree handles the details so families can focus on supporting their loved one.

Transitional Care Management Services

Based in Herndon and serving clients across Northern Virginia, ElderTree provides comprehensive support to ensure smooth transitions between facilities and/or home.

Doctor talking to patient over desk discussing a transitional care plan

Discharge Coordination

We work with hospital discharge planners and rehab staff on a transition plan, ensuring all care instructions, follow-ups, and next steps are clearly outlined.

Care manager sorting through medication for a senior

Medication Management

Medication changes often happen during care transitions. We review new prescriptions, resolve discrepancies, and ensure the individual understands their medication schedule.

Stethoscope and clipboard indicating a transitions care planning session for a senior patient

Appointment Management

Timely follow-up care is essential after a transition. We can schedule and coordinate transportation for follow-up appointments with physicians.

Senior man in a wheelchair talking to a caregiver in a nursing home.

Ongoing Monitoring and Support

Our support doesn’t stop after discharge. We stay in touch to ensure care plans are being followed, track progress, and address any issues that arise along the way.

Get Started Now

Moving a loved one from the hospital to home or rehab can be a confusing and stressful process. ElderTree’s transitional care management ensures every step is organized and every care need is addressed.  Take the first step today. Contact ElderTree in Northern Virginia today  to learn how our care management services can support you and your loved one through a safe, seamless transition.

Benefits of Transitional Care Management

Care transitions are a critical time when overlooking the smallest detail can have big consequences. ElderTree’s support ensures those details are managed, reducing the risk of complications and making each transition as smooth as possible.

Fewer Hospital Readmissions

Proper follow-through after discharge reduces the likelihood of avoidable hospital readmissions, keeping your loved one on the path to recovery.

Clearer Next Steps

We make sure families and individuals understand the discharge plan, follow-up care, and next steps so everyone feels confident about what comes next.

Communication Across Providers

We bridge the gap between hospitals, rehab centers, doctors, and specialists, ensuring every provider is aligned on the client’s care plan and goals.

Less Stress for Families

Managing a transition can be overwhelming, but ElderTree handles the details so families can focus on supporting their loved one, not coordinating care.

Your Partner in Every Step of a Transition

The days following a hospital discharge or rehab stay are often the most critical. ElderTree’s transitional care management bridges these gaps, ensuring a smooth, organized process from start to finish. By handling the logistics and maintaining clear communication with healthcare providers, we reduce the risk of setbacks and provide peace of mind for families.

Our involvement doesn’t end at discharge. We stay connected, ensuring that care plans are followed and any issues are quickly addressed. Our goal is to make every transition feel manageable whether it’s a move from the hospital to rehab or from rehab to home. With ElderTree on your side, you’ll never have to face these critical transitions alone. 

Contact us today to learn how our transitional care management services can support you and your loved one.

Older couple enjoying dinner after transitioning to a senior living home
Transitions care management by ElderTree
Senior man with a computer having a bright idea about his traditional care management plan
Elderly man with a laptop studying his transitional care management program
Senior man with a walker getting support after transitioning home from a hospital

Transitional Care Management FAQ

Find answers to common questions about transitional care management.

Transitional care management provides support and coordination when an individual moves from one care setting to another, such as from the hospital to rehab or from rehab back home. ElderTree ensures a smooth transition by managing discharge plans, coordinating follow-up appointments, assisting with medication changes, and maintaining clear communication with healthcare providers.

ElderTree works directly with hospital discharge planners, rehab facilities, and healthcare providers to create a clear transition plan. We can handle scheduling follow-up appointments, reviewing medications, and providing ongoing support after discharge. This allows families to focus on their loved one’s well-being instead of managing logistics.

ElderTree’s transitional care management services include discharge planning, medication review and management, appointment scheduling and transportation coordination, and ongoing support after discharge. Our care managers ensure that all follow-up care is addressed and that everyone involved in the client’s care is on the same page.

One of the biggest risks after discharge is returning to the hospital due to missed follow-ups or unmanaged medications. ElderTree reduces this risk by ensuring all discharge instructions are followed, follow-up appointments are scheduled and attended, and medication changes are reviewed and properly managed. This comprehensive oversight helps prevent unnecessary readmissions.

ElderTree remains actively involved even after your loved one returns home or moves to a new care setting. We provide ongoing support to ensure follow-up care is completed, address any issues that arise, and make adjustments to the care plan as needed. Our goal is to provide consistent, steady support throughout the entire transition process.

If your loved one is preparing for discharge from a hospital, rehab, or care facility, transitional care management can make the process smoother and less stressful. ElderTree handles the complex details of discharge planning, follow-up care, and provider coordination, ensuring your loved one’s health and safety remain a top priority.

Yes, ElderTree provides 24/7 access to the patient’s dedicated care management team. This means that if issues arise during the transition process — like medication confusion or questions about follow-up appointments — families can get immediate support and guidance around the clock.