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Rehab to Home 30-Day Transition Program

Because there’s no place like home, Peabody helps people get there faster.

The 30-Day Transition Program at Peabody’s Health Center redefines the typical approach to post-rehabilitative care. This unique program is designed to provide comprehensive follow-up after a short-term rehabilitative stay by implementing a customized plan that includes home visits by a Transitional Care Nurse in addition to ongoing contact via telephone during the 30-day period after discharge.

Our Purpose
To ensure a smooth transition from rehab to home and achieve the most successful outcomes possible, the 30-Day Transition Program provides:

• Verification of medication and orders for discharge with physicians
• Timely and consistent follow-up with primary care physicians, physician specialists, and home healthcare providers
• Transitional Care Nurse home visits that include physical assessments and recordings of vital signs and weight
• Assurance that physician orders are being followed correctly within the home setting

The program offers support for family members or caregivers as well, delivering personalized plans that include:

• Education to empower as much independence in managing personal health
• Support and education for family or caregivers, both before and after the Peabody’s Rehab to Home Program
• Initiation of direct readmission to Peabody if indicated by a health professional

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