Kindred Community Cares has adopted a 90-day transitional care model (TCM) that is a part of our overall case management services and is based on healthcare best practices.  Our TCM is designed to prevent health complications and re-hospitalizations by providing our patients with discharge planning that begins prior to discharge and continues once released from in-patient status.  Our staff integrate with healthcare providers to ensure a patient centered, comprehensive assessment of the patient’s health related social need, health behaviors, level of social support, and their health goals. Post discharge, our staff conduct periodic home visits and/or scheduled phone contacts with the patient based on an agreed upon protocol.