MISSION
Whether your transition is from the acute setting to home or from wanting cure focused care to care focused on symptom management and quality of life-We meet you where you are on the bridge to recovery , healing, or end of life care. We provide transitional, chronic and palliative care management using Nurse Practitioner house call visits to help prevent hospital admissions, coordinate your care, and treat symptoms, help manage chronic diseases, and address acute illness.
GOALS
Whether your transition is from the acute setting to home or from wanting cure focused care to care focused on symptom management and quality of life-We meet you where you are on the bridge to recovery , healing, or end of life care. We provide transitional, chronic and palliative care management using Nurse Practitioner house call visits to help prevent hospital admissions, coordinate your care, and treat symptoms, help manage chronic diseases, and address acute illness.
GOALS
- Coordinate the transition from acute care to the home environment in post acute patients. Help with transitions toward comfort and symptom control as chronic diseases progress in chronic and palliative patients.
- Provide patient care from a Nurse Practitioner that has the ability to assess, diagnose, treat, and prescribe medications
- Ensure timely follow up on recommended diagnostic tests and appointments after discharge from the acute setting
- Review and document all facility records, and provide a copy of important results to the patient for their PCP
- Assess patients and communicate findings and recommendations to their healthcare providers and home health
- Assess and address patient/family education needs regarding their diagnoses, medications, and treatment plan
- Coordinate with home health to provide orders for services, equipment, and changes to the plan of care
- If necessary, arrange for readmission to the Skilled Nursing, Long Term Acute Care, or Rehab facility within 30 days of discharge
- Determine an appropriate follow up schedule based on the current status and problems of the patients at the each visit
- Provide primary care as needed and able based on insurance to help avoid office visits in the frail , elderly, or advanced illness patients.
- Educate patients and families on medications, disease trajectory and management, advanced careplan issues