Post-Hospital & Transitional Care in Maitland & Central Florida

What this care looks like at home

We start most post-hospital cases within 24 hours of discharge from AdventHealth Orlando, AdventHealth Altamonte, Orlando Health ORMC, Winter Park Memorial, or another Central Florida hospital. Our care coordinator reviews the discharge instructions with the family, builds a care plan around what the client can and cannot do safely, and matches a caregiver who has experience with the specific recovery — hip replacement, stroke, cardiac, oncology, infection.

The first 72 hours home are the highest-risk window. A caregiver in the home during that stretch is the difference between a smooth recovery and a 30-day readmission. We confirm the new medication list against the discharge summary (it often differs from what the client was taking before admission), set up the recovery space — bedside commode, walker path, fall mats — and make sure the first follow-up appointments are on the calendar.

Each recovery has its own rhythm and we staff to it. Joint replacement clients need help with non-weight-bearing transfers, ice and elevation routines, and the patience to not push too soon. Cardiac clients — after CABG, stent, or a CHF admission — need daily weight checks, sternum precautions, and a quiet pace. Stroke recovery is medication-compliance and swallowing-safety first. Oncology clients in active chemo need fatigue management and nutritional support. Wound or infection recovery (cellulitis, MRSA, post-surgical) needs clean technique and a daily watch for fever or spreading redness.

Many clients also have a visiting nurse, OT, or PT through Medicare home health during the first few weeks. We work alongside them — they handle the clinical visits, we are the daily presence between visits, communicating anything we notice back to the home health team and to the family.

Day-to-day, we help with showers, dressing, medication reminders, meal prep, transportation to follow-up appointments at AdventHealth, Orlando Health, or the client's primary care office, and the kind of light supervision that keeps a recovering client from doing too much too soon. We also flag changes — new confusion, swelling, refusing to eat, an unexpected fever — to the family early, before they become a return trip to the ER.

Post-hospital care is often short-term. Many families across Maitland, Winter Park, Altamonte Springs, and Orlando start with a few weeks of high-coverage care and then taper down to a long-term part-time schedule once the client is stable. We make the transition gradual so there is never a cliff where help disappears.

• Often available within 24 hours of discharge
• Discharge instructions reviewed with the family
• Caregivers matched to the specific recovery type
• Medication reconciliation and follow-up appointment reminders
• Fall prevention, walker/cane assistance, safe ambulation
• Coordination with Medicare home health, OT, and PT visits
• Early warning of complications to the family
• Transitions smoothly to long-term or part-time care