Serving Jefferson County, Texas
The first 30 days after hospital discharge are the highest-risk period for readmission. Medications are new or changed, your body is deconditioned, wounds may still be healing, and the routines you need to follow at home are completely different from what happened in the hospital.
Our post-hospital care team steps in to manage that transition. A nurse visits within 24-48 hours of discharge to perform a thorough assessment, reconcile your medications, set up monitoring for any acute issues, and coordinate with your hospital team and primary care physician. If you need physical therapy to rebuild strength, occupational therapy to manage daily tasks, wound care, or infusion therapy, those services start immediately as part of one coordinated plan.
We serve these communities in Jefferson County:
Beaumont · Port Arthur · Nederland · Groves · Port Neches · China · Nome · Fannett
We coordinate with these local facilities:
Baptist Hospitals of Southeast Texas · CHRISTUS Southeast Texas St. Elizabeth · The Medical Center of Southeast Texas · CHRISTUS Southeast Texas St. Mary · Mid-Jefferson Extended Care Hospital
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What happens next
What we do
Response Time
We coordinate directly with hospital discharge planners. Most patients receive their first visit within 24-48 hours of arriving home.
24/7 RN On Call
Medicare 4.5-Star Rated
Serving SE Texas since 1995
Insurance & Coverage
We accept Medicare &
major advantage plans
Our team verifies your coverage and handles the paperwork so you can focus on healing. Not sure about your plan? Call us — we'll help you understand your benefits.
Common questions
Frequently Asked Questions
Usually the hospital's discharge planner or case manager places the referral. Physicians, family members, and patients can also request home health directly.
The typical episode is 30-60 days, depending on your condition and recovery progress. Some patients need a few weeks; others need several months.
Home health includes skilled nursing, physical therapy, speech therapy, occupational therapy, and medical social work — clinical services ordered by a physician. A home health aide provides personal care assistance as part of that clinical plan.
Also available nearby
Care After Hospital Discharge in neighboring counties
Ready to get care in Jefferson County?
Contact us today. A nurse is always available to discuss whether home care is right for your situation.
For life-threatening emergencies, always call 911.