Hospital readmissions within 30 days are a leading quality metric for discharge planners at Valley Baptist Medical Center, Valley Regional Medical Center, and South Texas Health System. Our transition care service bridges the gap between discharge and full recovery, reducing readmission risk through consistent, supervised in-home support and real-time care coordination.
What We Provide
- Same-day or next-day care start following hospital discharge
- ADL and IADL assistance tailored to post-acute recovery needs
- Medication reminder support and follow-up appointment accompaniment
- Observation and reporting of warning signs to MCO coordinator or family
- EVV-verified visits documented in real time for care continuity
- Direct intake coordinator available for discharge planners — fax and phone
Who Is Eligible
Patients being discharged from any RGV-area hospital enrolled in STAR+PLUS, PHC, Driscoll Health Plan, or private pay. Discharge planners and MCO coordinators can call (956) 594-8188 to initiate a referral with a 24–48 hour care start commitment.
Programs That Cover This Service
STAR+PLUS HCBSSTAR+PLUS State PlanPHC — Primary Home CareDriscoll Health PlanPrivate PayLong-Term Care Insurance