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Transitional Support After Hospital Discharge

Post-discharge care coordination

Short-term, in-home and virtual care coordination and support from our nurses designed to help you transition safely home during the critical days after discharge, while long-term care is arranged if needed.

About Soluna Care Network

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At Soluna Care Network, our nurses specialize in short-term support and care coordination after hospital, rehab, or facility discharge. We serve as a trusted hub that connects providers, guides families, and keeps care aligned so nothing falls through the cracks during the early recovery period while longer-term care is arranged if needed.

Our Specialized Services

Care Transitions

We specialize in supporting smooth transitions from hospital, rehabilitation, or facility settings back to home. Our focus is on coordination, communication, and continuity to ensure care plans are understood and supported and helps set the stage for longer-term care as needed.

Care Coordination & Navigation

We help align care across providers, services, and settings by coordinating appointments, services, and communication serving as a central point of guidance for families.

In-Home Support Services

We coordinate in-home support resources and provide short-term transitional guidance and education to help families manage care safely in the days immediately following discharge. This is not ongoing skilled nursing care.

Family & Caregiver Guidance

We provide education and guidance to families and caregivers, empowering them to make informed decisions and feel confident managing care at home.

Post-Discharge Support

We offer follow-up coordination after discharge to help ensure services are in place, concerns are addressed early, and recovery stays on track during the initial post-hospital period.

Medication & Care Plan Support

We assist individuals and families with understanding care plans and medication routines through education and care coordination. We may assist with organizing medications into pill organizers based strictly on current provider instructions. Soluna does not manage, administer, adjust, or monitor medications.

Soluna Care Network provides short-term transitional support and care coordination after hospital discharge. Hands-on medical care may be provided by licensed clinicians under existing provider orders when appropriate. Soluna does not operate as a home health agency; our role is care coordination, education, and short-term transitional support.

Benefits of Choosing Soluna Care Network

Compassionate, Patient-Centered Approach

Personalized Care Coordination

Seamless Transitions & Communication

Trusted Guidance

Short-Term Transitional Support

Collaborative Approach

By the Numbers

What We Provide

5-Day Transitional Support Package – $549
Private-pay. No insurance billing.

Day 1

In-Home Transition Visit

A nurse meets you at home after discharge to help you settle safely, review discharge instructions, assess immediate needs, assist with mobility, reinforce wound care orders if applicable, and organize medications into a pill box if needed.

Day 4

Clinical Telehealth Check-In

A virtual clinical check-in to review symptoms, answer questions, confirm follow-up appointments, and coordinate communication with providers as needed.

Day 2

Follow-Up Nurse Visit

A second in-home visit by the same nurse to reassess recovery, reinforce education, monitor wounds under existing orders, address questions, and ensure the care plan is on track.

Day 5

Optional Extended Support

An optional additional check-in for families who want continued reassurance, education, or coordination during the first critical week at home.

Day 3

Social Work Support (Virtual)

A licensed social worker provides a virtual check-in to support care planning, resources, caregiver needs, and next steps for ongoing services if needed.

Day 6 & Beyond

Care Navigation

If ongoing support is needed, we help coordinate next steps such as home health, outpatient services, private caregivers, or community resources.

Get in Touch

Elderly Support Interaction
Soluna Care Network provides private-pay care coordination, education, and short-term transitional support. We do not bill insurance or Medicare.

Contact Us

(855) 5-SOLUNA
(855) 576-5862

Address

Kyle, Tx

Soluna Care Network provides private-pay care coordination, education, and short-term transitional support following hospital discharge. Soluna is not a home health agency and does not provide ongoing skilled nursing services or long-term care. 

In an emergency, call 911 or contact your healthcare provider.

© 2025 by Soluna Care Network

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