Chronic Care

CHRONIC CARE -By bringing a physician or nurse practitioner to you, our Chronic Care team helps us to manage complex care needs in the home. This team-based approach emphasizes collaborative care and strengthens the role of your Home Health team, primary care physician and specialists to help you thrive!

  • Manage complex care needs of patients with chronic conditions such as cancer, heart failure, lung disease, liver disease, chronic pain, and dementia.
  • Reduce the need for urgent hospitalization and ER visits
  • Coordinate Care with doctors, home care, home health, hospice and medical equipment
  • Social Worker support to help cope with depression and anxiety, caregiver stress, advocacy, community resource specialist and much more.

Transitions Team Approach-You do NOT need to go to the hospital in-order for Medicare to cover your home health care. The Transitions Home Health Care team strives to meet you before you get the point of needing to go to the ER. However, if you end up in the hospital or a skilled nursing facility, we would love to come meet you there before returning home as well to help prepare you for a successful return.

In your home we are charged with recognizing symptoms of distress through regular medical monitoring. The RN will regularly take your vital signs, and monitor all of the concerns specific to your health care needs. It can be impossible for you to go to your PCP or Specialist in this crucial time of transition. We come to you. The home health care team includes the RN, PT, OT, ST, MSW, CNA and medical oversight by MD and Nurse Practitioner. During the weeks following your hospitalization while you are basically home bound, you can count on frequent visits and 24/7 phone support. Occasionally visits by the Transitions Chronic Care team may be needed, and are available to the Transitions Home Health Care patients. Together they provide the optimal coverage in complex condition management.

Indicators for home health: In order to receive home health, a patient must have a skilled medical need. Here are a few examples: medication or disease process education and management, history of falls/fall prevention, recovery from falls/ breaks, deconditioned, needing evaluation for durable medical equipment (such as walker or wheelchair), wound care, medication, new living environments, high blood pressure, frequent bladder infections, heart disease, lung disease, liver disease, chronic pain, cancer, Parkinson’s, depression, anxiety, and various types dementia.

Transitions Home Health Care