Our Services in the DFW area Include:
- Post Acute Transitional care (30-60 days of weekly NP visits after an acute admission,
- Chronic care management/house calls, Palliative Care-routine NP visits chronically with a focus on disease management, prevention of hospital admissions, communications with other providers, educations, symptom management.
- Medication reconciliation to prevent medication errors
- Order Mobile X-Rays, Labs, or other Diagnostic Tests as needed
- Patient phone contact by within 2 business days of discharge
- NP visits at their residence within 7 business days of discharge from an acute facility then every 1-2 weeks until stable
- Refill and adjustment of prescriptions
- Risk assessment at visits to determine risk of readmission and frequency of follow up visits indicated
- Coordination of care and communication with home health, PCP, and specialists
- Thorough review of hospital records with follow up on labs, diagnostics, or orders. Records are left with the patient for their PCP
- Education of the patient/family on their diagnoses, disease processes, medications, follow up appointments, and discharge instructions
- Assistance with coordinating readmission to the acute care/rehab system if indicated
- Referral of patients to our partner facilities as needed
- Nurse Practitioner on call triage services during 30 days post discharge period after office hours and weekend
- Recommendations to other providers involved in the patient's care