Transitional Care

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Our transitional care platform incorporates “Care Team” philosophy with integrated post-acute services and case oversight. These resources include:

• Case Management
• Mobile Physician
• Nursing
• Nutrition
• Outpatient Treatment Centers or Clinics
• Patient or Family Member Support
• Personal Care Attendant
• Personal Care Coordinator
• Pharmacy
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Primary Care Doctor
• Psychological Support
• Social Worker
• Specialist Physicians
• Transportation

Each patient will receive a comprehensive assessment and a treatment plan to ensure the best possible outcome. And, we’ll communicate with you and other care team providers to keep you apprised of the patient’s status as well as identify other potential diagnoses.

Our transitional nurse or home health physician will be available to visit with the patient prior to discharge. After a comprehensive assessment of the patient, resources and challenges, the patient’s post-care is organized with the care team. The patient and family are educated on “What’s Best Next” and services are booked and ready for post-discharge delivery.

An RN or physician consults with the patient 12 to 24 hours before discharge. Based upon medicare standards we will perform an Oasis evaluation , full medication reconciliation , fall risk assessment and a mandatory pos-acute physician visit will be scheduled. During the risk period, patients receive phone calls from the care team as often as needed to ensure program compliance and medication adherence as well as bond with the nursing department.

If a patient is a high risk chronic condition(s)they will be enrolled in our long term care program. Because patients have a strong tendency to fail after hours and on weekends, we’re available 24/7 via phone, video conference and in person.

Once a patient has been successfully transitioned for 30 consecutive days, we’ll perform periodic health checks to head off potential health issues, answer questions and identify new diagnoses. These health checks are performed as often as needed based upon each patient’s unique needs.