Our hospitals and rehabilitation centers do a wonderful job of helping people get through a crisis and progress to where they can return home. So, why do so many of those individuals end up back in the hospital?
Our team can help prevent readmissions and here is how we do it:
Transitions of Care Program
The following services help clients remain independent and avoid the need for readmission to higher levels of care.
One of our nurses will:
- Meet with the discharge planner, case manager and/or social worker to receive a copy of the discharge instructions and medications list and participate in care coordination processes
- Meet the client upon their return home, perform a thorough assessment and create a personalized care plan
- Provide introduction for the client to their caregiver(s)
- Promote awareness regarding client condition
- Provide medication reminders and monitor adherence to medication regimen
- Assist with scheduling follow-up medical appointments and provide transportation if needed
- Provide assistance with practicing assigned exercises between home health appointments
- Assist with bathing, grooming, dressing and personal hygiene
- Pick up prescriptions, groceries and assist with light housekeeping, laundry and meal preparation as needed
- Provide companionship to alleviate depression