Doctors, patients and loved ones trust us to provide seamless care and monitoring when patients are preparing for discharge from the hospital to their home or assisted/independent living facility.

When a physician refers a patient to us for home health care, our planning begins while the patient is still in the hospital. Our Patient Care Coordinator meets personally with the patient and family members to get to know the patient's needs, review a “Discharge Preparation Checklist,” provide a Patient VIP card with our contact information and explain the use of the “Personal Health Record.”

When prescribed, our clinicians continue the patient's treatment at home, coordinating communication with the doctor and helping the patient work toward recovery and continued independence. 

Patients Who Qualify for Transitional Care

• Primary Diagnosis of at least one of the following: heart failure, acute myocardial Infarction (AMI), coronary artery disease, cardiac arrhythmia, COPD, CVA or pneumonia
• 65 years or older with traditional Medicare
• Recent hospitalization (non psychiatric)

• Emphasizes coordination and continuity of care, prevention and avoidance of complications and close clinical treatment and management
• Clinician visits patient initially in hospital and begins process of medication reconciliation and assures physician follow up
• Coordination with facilities, physicians, the patient and their family
• Comprehensive in-hospital planning and home follow up
• Post discharge Transitional Care Coordinators maintain contact with patient to promote continued compliance and stabilization