Home Health

Home Health–Comprehensive care which can include Nursing, Physical Therapy, Occupational Therapy,  Speech Therapy, Social Work, and CNA. Our unique approach promotes well-coordinated care as patients move across care settings. We reduce complications and hospital readmissions, while providing support to the caregiver. Intern, providing a higher quality of life for our patients!

  • First visit within 24-48 hours/as requested
  • Supported by Transitions Chronic Care team for patient’s whose status changes & need ongoing symptom management
  • Staff recognizes early signs of distress reducing hospital visits
  • Dual level care increases support to patients & family to improve quality of life
  • Community resource referrals for ongoing support & independence

Homebound?— A patient is considered “homebound” under Medicare if the patient cannot safely leave home without “considerable and taxing effort” or psychiatric symptoms interfere with ability to safely leave home. Patients are allowed infrequent and short in duration absences from their home including:  medical appointments, religious services, adult daycare or unique events such as funerals, graduations or trips to the barber.

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