Transitional care management
after a hospital or facility stay.
Support after a hospital or qualifying facility discharge, including timely outreach, medication reconciliation, follow-up coordination, and help navigating the next phase of recovery.
Every handoff is a
chance to keep
the plan connected.
Care can become fragmented when patients move between the hospital, skilled nursing, home health, and everyday life. Questions about medications, follow-up appointments, and what to do next often come up right after discharge.
Trinity helps connect the plan, so patients and families have support beyond a single visit or episode.
“Care does not stop when
the episode ends.”
Timely outreach and
a clearer next step.
- Timely outreach after discharge
- Medication reconciliation
- Follow-up coordination and post-discharge follow-up
- Care handoffs between settings
- Help navigating the next phase of recovery
A stronger handoff
back to the community.
Hospitals, discharge planners, skilled nursing facilities, and home health agencies can refer patients who would benefit from support after they leave a facility. We work with your team, with clear roles and timely communication.
To refer a patient, call us, fax us, or use our online referral form. Our intake team will tell you what information we need.
Delivered by telehealth,
wherever you are.
Everything is delivered by telehealth, so no in-person visit is required, anywhere in Texas. Family members and caregivers can be involved with the patient's permission.
Coverage and out-of-pocket costs depend on the program, insurance benefits, and individual eligibility. Our team reviews available benefit information and discusses potential patient costs before enrollment.
From the first conversation
to a coordinated plan.
Connect
A patient, family member, or healthcare partner contacts Trinity to discuss a need.
Understand
We review clinical needs, program fit, coverage, and the patient's existing care relationships.
Plan together
With patient consent, we establish goals and coordinate the next steps with the care team.
Stay connected
Ongoing outreach, education, and communication help keep the plan moving forward.
Better care begins
with a conversation.
Refer a patient, ask about a program, or explore a partnership. Our intake team can help identify the right next step. Telehealth across all of Texas.