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HOSPITAL DOCS PA
Compassionate Care At A Critical Moment
Post Acute Care
Compassion, Continuity, & Coordination After Hospital Discharge
At Hospital Docs PA, our care doesn't end at hospital discharge — it evolves. We remain by the patient’s side throughout their recovery journey, providing attentive post-acute care across Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs), and Long-Term Acute Care Hospitals (LTACHs).
Grounded in Compassion, we care for each patient as if they were our own—understanding the challenges that come with healing outside the hospital walls. Through seamless Coordination with facility staff, case managers, and primary care providers, we ensure treatment plans are clear, timely, and responsive to changing needs. And with a deep commitment to Continuity, we bridge transitions from hospital to recovery, keeping communication open and consistent to prevent unnecessary setbacks.
By combining clinical expertise with human connection, we aim to not only improve outcomes—but also reassure patients and families that they’re never navigating recovery alone.
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Our Post-Acute Services Include:
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Daily or On-Site Rounding by Our Providers
Consistent medical oversight allows for early identification of issues, timely treatment adjustments, and improved patient outcomes. -
Dedicated Patient Liaisons
Serving as a communication bridge between patients, families, facility staff, and referring providers to ensure everyone stays informed and supported. -
Real-Time Updates to PCPs & Referring Providers
We keep primary care teams in the loop with timely updates and progress reports throughout the patient’s recovery. -
24-Hour / 72-Hour / 31-Day Post-Discharge Follow-Up Calls
Our team checks in at key intervals to monitor symptoms, clarify medications, confirm follow-up appointments, and address social needs—helping prevent unnecessary readmissions. -
Coordinated Transitions Across All Phases of Care
From hospital discharge to rehabilitation or skilled nursing, we ensure a smooth, connected experience that prioritizes continuity and quality at every step.