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Transitional Care

Transitional care is designed to help patients get back on their feet safely after a hospital or rehabilitation stay because of an illness or surgery. Our staff will help you with things like medication management, prescription knowledge and understanding, house calls, Telehealth, and more. MidSouth Transitions Medical Group will help put in place any services you may need at home to help you continue your recovery.

We Value Partnership

MidSouth Transitions Medical Group values partnerships.  We wouldn't be able to provide exceptional care without our partners. We work with following: Hospitals, Rehabilitation Hospitals and Facilities, Skilled Nursing Facilities, Physicians, Specialists such as Oncologists, Cardiologists, Pulmonologists, and more; Home Health Agencies, Palliative Care companies, DME companies, Pharmacies, Out Patient Therapy, the local community, and so many more to ensure patients receive the best post acute care.

Hospital to Home

Hospital to Home transitional care focuses on the patients post acute needs. One of our primary goals is to help reduce hospital readmission. We provide midlevel APN care in the home to improve continuity of care as the patients transition from an inpatient setting back to their home. We can temporarily bridge the gap for patients that are not yet established with a PCP (Primary Care Physician) and help with a referral to a PCP of patient's choice if they do not already have one.  We help educate and drive compliance. Seeing the patient twice a week allows us to adjust the patients needs quickly. Patients discharging from an in patient stay qualifies them for transitional services. (pending eligibility and insurance authorization)

House Calls
Home-based transitional care focuses on the whole patient and provides direct, ongoing care for medical, emotional, and social needs, and diagnostic testing. Home visits identify problems that might not be uncovered during an office visit—such as patients using the wrong medicines, fall risks in the home, or pets being around someone who has severe breathing problem. Services include administering IV fluids and medications, wound management, ordering medical equipment, etc.

Telemedicine & Telehealth

Telemedicine allows health care professionals to evaluate, diagnose and treat patients at a distance using telecommunications technology. The approach has been through a striking evolution in the last decade and it is becoming an increasingly important part of the American healthcare infrastructure. With Telehealth we can focus on a broader array of digital healthcare activities and services.

Clinical Pharmacy

Our clinical pharmacists work directly with physicians, other health professionals, and patients to ensure that the medications prescribed for patients contribute to the best possible health outcomes. 

Dietary & Nutrition

MidSouth's Registered Dietician will assist patients with meal planning, health education, supplemental nutrition, diabetic knowledge and much more.

What We Do

  • Order Medication refills and provide education

  • Order DME (Durable Medical Equipment) such as walkers, wheelchairs, oxygen, and more

  • Order in home labs, x-rays and other tests if needed

  • Coordinate with Home Health and Therapists

  • Coordinate referrals to specialists, skilled facilities, inpatient rehabilitation, and outpatients therapy

  • We do not replace your doctor, we coordinate with them in the transitional period (up to 90 days)

  • If you don't have a doctor, we can help you establish one 

  • We can help you find additional resources

  • Dietician and Pharmacist available

How to Refer

  • Self referral?  Just give us a call 430-200-4350

  • We need the patient's Face Sheet including demographics and insurance information, History and Physical, medication list, and a discharge summary if available.

  • Email or Fax to 866-337-1615

  • We verify benefits and communicate during and after the approval process.

  • We schedule patient to be seen by a Nurse Practitioner within 24-72 hours.

A nurse taking card of old patient
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