A defined episode of nursing visits to move you from one level of care to the next.
Some recoveries don’t end at discharge, and don’t fit neatly into a single program either. Andreen Robinson, MSN, RN builds a scoped plan around your specific clinical need, with clear goals and a defined end point, hands-on care and follow-through, by appointment.
Recoveries that need a scoped plan, not a single visit or open-ended coverage
- Patients moving between levels of care (hospital to rehab to home, or stepping down from a higher level of attention)
- Recoveries involving more than one clinical need at once, where a single program doesn’t cover the full picture
- Families who want a defined plan with clear goals, not an indefinite arrangement
- Patients whose situation calls for the same RN tracking progress across the full transition
What this is
- A clinical need and goals defined together before the engagement begins
- Hands-on care, like wound checks or medication administration, when clinically appropriate and provider-ordered
- Visits scheduled across the agreed transition period, with the same RN throughout
- Flagging concerns to the treating provider promptly as the plan progresses
What you’ll leave with
A scoped plan with a defined end point: nursing care through the transition, and a written hand-off once the goals are met.
Set at the start of the engagement based on your specific clinical need, typically days to a few weeks, and reassessed if circumstances change.
A clearly defined outcome agreed before visits begin, for example, a successful step-down to self-management, or readiness for the next level of care.
Each engagement ends with a written summary and a plan: self-management at home, referral to one of HVPN’s other programs, or a hand-off to the next appropriate level of care.
Situations this program helps with
A patient stepping down from a skilled nursing facility to home with two ongoing clinical needs—wound care and medication management. Neither the Post Hospital Recovery Program nor one standalone service fully covers the picture.
A post-surgical patient whose home health agency ended services. He still needs nursing oversight for a few more weeks but doesn’t qualify for agency re-certification.
A family managing a complex recovery at home who wants a single RN tracking everything across the transition—not passing information between providers or programs at each handoff.
What families ask before scheduling
How is Transitional Care different from Post Hospital Recovery?
Post Hospital Recovery is for the standard window after a hospital or surgical discharge. Transitional Care is for situations that don’t fit that structure—more than one clinical need at once, a longer or more complex transition, or a recovery spanning multiple care settings.
How many visits does a typical episode include?
This is defined at the start based on your specific situation. We set clear goals together before the first visit, and the number of visits follows from that plan—not from a preset package.
What happens if my situation changes during the episode?
We reassess at each visit. If something changes significantly, we adjust the plan and communicate with your provider accordingly.
Who sets the goals for the episode?
We do, together, before the engagement begins. Goals are specific, clinical, and tied to a defined end point so the plan doesn’t become open-ended.
Do I need physician orders for Transitional Care?
For any hands-on clinical care included in the plan—wound care, medication administration—provider orders are required where clinically indicated. Education and care coordination do not require orders.
Can Transitional Care include more than one type of care?
Yes. This is the program designed for exactly that: a recovery involving multiple clinical needs that benefit from a single coordinated plan and the same RN throughout.
When another provider may be more appropriate
HVPN does not provide continuous or daily nursing coverage, nurse staffing, or Licensed Home Care Services Agency-level care. Transitional Care means a defined episode with clear goals and an end point, not ongoing shifts or around-the-clock access. See our Terms of Use for full service scope.
Request a consultation
A brief, no-obligation conversation to define the clinical need and plan a schedule.
Request a ConsultationYou may also need: Post Hospital Recovery Program or Healthcare Navigation & Care Coordination Support.
A defined plan for the transition, with a clear end point in sight.
Request a consultation to scope the clinical need and plan a schedule.
Request a Consultation