Hospital to Home Care Transition Program

Clients & Families:

Transitioning from a hospital setting, rehab center, or skilled nursing facility can be a cumbersome process but luckily, we can take that off your shoulders. Whether you want to go to a facility or straight home, you want someone who has your best interest and is on top of the details that matter. Our registered nurse will meet with you to discuss specifics and complete the necessary paperwork before we can arrange to have you transported. If your trip requires special equipment or luggage, we’ll make arrangements for that as well. We help make it easy for you to quickly adjust back to your daily life, hence minimizing the risk of hospital re-admissions and promoting a healthy positive environment so you can get back to speed quickly and effectively. The following services are typical during the transition, though the exact program would depend on your situation and requirements:

• Meet with clients at the hospital or facility and obtain discharge instructions
• Update care plan as appropriate, ensuring adherence to the prescribed regimen
• Pickup any medications, prescriptions, clothing, among other necessary items
• Safety recommendations around the home, clearing the path, reducing hazards & other risks
• Ongoing home care and companion support
• Medication reminders, exercise prompts, emotional well-being and physical support
• Encouraging wellness, proper hydration and balanced nutrition while following your diet restrictions suggested by your physician or discharge planner
• Transportation to follow-up appointments, rehab sessions or other personal events
• Educate family members and caregivers about appropriate care procedures, applicable situations, and red flags to minimize risk for chronic conditions
• Continuous updates and communications with your loved ones, physicians, discharge planners, among other health care professionals as needed