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Transitional Care

Presidium Health’s Transitional Care Program

Transitional care refers to a broad range of healthcare services and supports that ensure continuity and coordination as individuals transfer between different locations or levels of care. Some examples include movement from home to a skilled nursing facility, hospital to home, emergency department to home, residential treatment center to home, and housed to unhoused. Our transitional care program is built to move with the individual. We prioritize addressing gaps that often emerge during changes in care settings.

Who Receives Transitional Care

Our services are intended for all participants in any one of our care programs.

Key Features of Our Transitional Care Program

Agile Case Management. A case management approach that addresses the immediate needs consequent to a transition while maintaining a focus on longitudinal outcomes.
Engagement. Patient and family engagement is prioritized as an essential to maintaining long-term health.
Collaboration. Partnerships with care team members across all settings to create and carry out a unified plan.
360 View. Comprehensive planning that addresses medical, social determinants of health, mental, financial, and access needs.
Continuity of Care. A service approach where continuity transcends the change in care setting.

Care team member providing transitional care to a patient at home

Patient experiencing transitional care event arrives home to eviction notice

Learn How Social Factors Influence Successful Care Transitions

Transitional care’s success is deeply influenced by non-medical factors like housing instability, transportation access, food insecurity, education, and social support. The most effective Transitional Care Programs bridge clinical care and social reality- transforming isolated interventions into equity-centered, human-first outcomes.

See How Social Factors Matter

Learn More About Coordinated Transitional Care Services & Enhanced Care Management

What starts at discharge doesn’t end there. Transitional Care lays the groundwork for successful Enhanced Care Management by identifying risks early, closing gaps in care, and building trust with high-need patients. See how seamless care transitions drive better outcomes—and set the stage for long-term stability.

Boost Transitions With ECM