The Next Step in Your Care Starts Here
Hill Country Transitional Care Medicine exists to deliver exceptional, physician-led transitional care that bridges the gap between hospital, post-acute care, and home. We combine compassionate clinical oversight with innovative remote patient monitoring and timely follow-up to ensure every patient returns home safely and stays home longer. By partnering closely with primary care providers, we equip them with tools and support to manage complex patients effectively—without increasing office burden or wait times. Our mission is to improve outcomes, reduce readmissions, and strengthen the continuum of care for our community.
Our Services
Advanced Monitoring. Better Transitions.
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Continuous monitoring of patients with chronic conditions using real-time data collection and clinical oversight to improve patient outcomes.
Continuous Monitoring
24/7 data collection from blood pressure monitors, weight scales, pulse oximeters, and glucometers.
Real-time Alerts
Immediate notifications for out-of-range values with care team escalation protocols.
Improved Outcomes
Early intervention capabilities leading to reduced hospitalizations and better patient health.
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Monitor patient therapy adherence and treatment outcomes using digital health tools. RTM focuses on tracking therapeutic interventions and patient engagement with treatment plans.
Therapy Tracking
Monitor medication adherence, physical therapy progress, and treatment compliance.
Digital Therapeutics
Evidence-based digital interventions for various therapeutic areas.
Outcome Measurement
Track patient-reported outcomes and therapy effectiveness metrics.
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Transitional care visits from the hospital focus on ensuring a smooth transition for patients returning home or moving to another care facility. Key points include timely follow-up appointments, medication management, and coordination of ongoing care to prevent readmissions and support recovery.
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Our Mission
Hill Country Transitional Care Medicine exists to deliver exceptional, physician-led transitional care that bridges the gap between hospital, post-acute care, and home. We combine compassionate clinical oversight with innovative remote patient monitoring and timely follow-up to ensure every patient returns home safely and stays home longer. By partnering closely with primary care providers, we equip them with tools and support to manage complex patients effectively—without increasing office burden or wait times. Our mission is to improve outcomes, reduce readmissions, and strengthen the continuum of care for our community.
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Our Philosophy
Our care philosophy is rooted in dignity, compassion, and partnership. We believe every patient deserves care that honors their whole-person needs—clinical, emotional, social, and spiritual—while empowering them and their families to make informed decisions with clarity and confidence.
We strive to build trust through evidence-based practice, transparent communication, and a commitment to meeting patients where they are. Whether in the hospital, at home, or within complex systems of care, our goal is to ensure patients feel seen, supported, and respected.
As physician leaders, we work to strengthen care models that enhance safety, reliability, and equitable access. We are dedicated to creating environments where clinicians can deliver their best care and where operational excellence elevates the patient experience.
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Our Vision
To transform the Hill Country’s transitional care landscape by creating a seamless, reliable, and physician-supervised bridge from hospital to home—empowering patients to thrive where they heal best. We envision a future where avoidable readmissions are rare, primary care teams are supported with advanced monitoring and coordinated follow-up, and every patient experiences continuity, safety, and confidence during recovery. Hill Country Transitional Care Medicine will set the regional standard for innovative, community-rooted transitional care.
About Us
Hill Country Transitional Care Medicine is a physician-founded practice dedicated to helping patients safely return home after hospitalization or post-acute care.
Our innovative model supports patients during the most vulnerable phase of recovery while giving primary care providers real-time tools to manage complex patients without increasing office burden. We provide close, physician-supervised monitoring, timely follow-up, and seamless coordination with primary care to prevent complications and reduce readmissions. Rooted in deep clinical experience and community-focused leadership, we ensure every patient receives the continuity, safety, and guidance they need to recover confidently at home.