90-Day Transitional Care Coaching

A 90-day coaching program built to keep your loved one home, not back in the hospital.

JD&L Global Care Management works alongside families for 90 days after a hospital stay, closing the gaps that lead to repeat admissions — so your loved one recovers at home, not in a hospital bed.

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1 in 5

Medicare patients are readmitted to the hospital within 30 days of discharge

34%

are readmitted within 90 days — the exact window this program covers

~50%

of patients readmitted within a month never saw an outpatient doctor first

1 in 4

heart failure patients specifically return within 30 days

Sources: Jencks et al., New England Journal of Medicine; JAMA condition-specific readmission data.

Why the first 90 days matter most

Most repeat hospitalizations happen in the weeks right after a discharge — a missed medication, a follow-up that never got scheduled, a warning sign no one recognized in time. JD&L Global Care Management pairs your family with a dedicated transitional care coach for a full 90 days, closing exactly those gaps, so recovery continues at home instead of circling back to the ER.

The 90-day program

Three phases, one coach, from discharge day to stable at home

Days 1–30

Stabilize

We meet your family before or right at discharge, review medications, confirm follow-up appointments, and flag the risks most likely to trigger a return trip.

Days 31–60

Reinforce

Regular check-ins catch small problems early — a missed refill, a new symptom, a caregiver running low on support — before they become an ER visit.

Days 61–90

Sustain

We hand off to a long-term routine your family can maintain independently, with a clear plan for what to watch and who to call if anything changes.

What's included

Everything a family needs to keep recovery on track at home

Discharge Planning Review

We go through discharge paperwork line by line with your family, so medications, restrictions, and follow-ups are understood before you leave the hospital.

Medication Management

Missed or mismanaged medications are a leading cause of readmission. We set up a system your family can actually follow.

Follow-Up Coordination

We schedule and confirm every follow-up appointment, and make sure someone shows up — including transportation if it's needed.

Warning Sign Coaching

Families learn exactly which symptoms mean "call the coach" versus "call 911," so small problems get caught before they become emergencies.

Weekly Check-Ins

A consistent point of contact throughout all 90 days, so nothing gets missed between appointments.

Caregiver Support

We coach the family caregiver directly — not just the patient — since caregiver burnout is often what leads to a preventable ER visit.

Understanding your condition

Practical, plain-language info to help you manage day to day — not a substitute for medical advice

Managing High Blood Pressure

Take medications at the same time every day — consistency matters more than perfect timing
Limit sodium; read labels, since sodium hides in bread, sauces, and canned foods
Track your numbers at home so patterns show up before a crisis does
Call your care team if you're consistently above 140/90 or feel dizzy, short of breath, or have chest pain

Managing Blood Sugar

Consistent meal timing helps keep glucose levels more predictable
Know your personal target range — it varies person to person, so confirm yours with your doctor
Watch for signs of low blood sugar: shakiness, confusion, sweating — treat these right away
Keep a simple log; trends over weeks matter more than any single reading

This information is educational and general in nature. It does not replace personalized medical advice — always follow your own care team's guidance.