Post-Hospitalization Care at Home in Naples, FL

A Safer Transition Home After a Hospital Stay

My Medical Family care plans manage the complex transition for a patient going home after a hospitalization.

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The My Medical Family approach includes:

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• Intensive Coordination: Assign a primary nurse contact for the patient and provide a plain-language summary of their hospital care.

• Rapid Follow-Up: Schedule an immediate home health visit (within 48 hours), a doctor visit (within 7 days), and weekly check-ins for the first month.

• Home Rehabilitation: Send an interdisciplinary team (Physical Therapy, Occupational Therapy, Dietitian) to the home to treat physical, cognitive, and mental health issues associated with Post-Intensive Care Syndrome (PICS).  For cardiac events, this may be participating in a cardiac rehabilitation program.

• Full Support and Collaboration: Actively assess and support the caregiver, ensuring that all providers (SNF, home health, primary care, specialists) communicate and review the patient's advance care plans.

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This plan is always personalized to the patient's specific condition and needs.

Let’s Talk About Your Post-Hospital Care Needs

Have questions about our post-hospitalization care services or how we can support your family? Send us a message and a member of our care team will reach out shortly.