Post-Discharge Care Model (Transitions+)

Post-Discharge Care Model – Transitions+

Transitions+ is a structured, scalable homecare model designed by ForCare to support patients during the critical period after hospital discharge. It aims to reduce readmissions, enhance patient safety, and ensure continuity of care by bridging the gap between inpatient treatment and home-based recovery.

🔹 Core Components

• Care Navigation Tools:

  • Personalized care plans aligned with hospital discharge summaries

  • Structured communication between hospital staff, ForCare nurses, and primary physicians

  • Assigned care coordinator to manage follow-ups and escalation protocols

• Patient Tracking Templates:

  • Daily logs for vital signs, medication adherence, nutrition, and mobility

  • Digital and printable versions for use by caregivers and visiting nurses

  • Shared access with physicians for real-time decision-making

• Quality Indicators & Reporting:

  • Metrics on readmission rates, symptom control, caregiver burden, and protocol adherence

  • Weekly status reviews and red flag alerts

  • Integration with ISO 15224 and quality audit preparation

🔹 Ideal for Pilot Integration

• Hospitals looking to reduce 30-day readmission penalties

• Municipal or regional health authorities seeking continuity-of-care programs

• Public-private collaborations focused on elderly, neurological, or chronic disease populations

• Research teams studying real-world outcomes in community-based care

💡 Transitions+ provides a practical, low-cost model that is easy to replicate and adapt, making it a valuable tool for modernizing hospital discharge and post-acute care in Greece and beyond.

📩 Interested in piloting or co-developing Transitions+?
Contact: vagelis.sarikas@forcare.gr