Our team is trained by our Medical Director to recognize early signs of distress reducing hospital visits. First visit within 24-48 hours or as requested.
We are supported by Transitions Chronic Care team for patient’s whose status changes & need ongoing symptom management. Our staff recognizes early signs of distress reducing hospital visits. With dual levels of care, we increase support to patients & family to improve quality of life. Transitions has a vast network of community resource for referrals to provide ongoing support & independence.
Services are as the referring doctor refers and may include: RN, PT, OT, ST, SW, BHRN
Paid by Medicare A /insurance (100%, no deductible)
Unlimited number of benefit days, come in 60 day increments/episodes
- Medication Management
- Advanced Directives
- Fall Prevention programs
- Pain Management with therapy and nursing
- Post-Op Rehab: spine, Ortho, knee, hip, heart, amputations, and lungs
- Diabetes- disease & nutritional education, insulin education, medication management, foot/wound care
- CHF/ COPD –‘Front-load’ nursing & therapy to keep patients risk significantly down from being admitted to hospital.
- Cancer– Is patient weak at home after chemo? Getting dehydrated? Struggling with nutrition?
- Behavioral Health– Depression, Resources, Med Review
- 24 /7 triage nurses, Start of Cares can begin on weekends
We collaborate closely with Independent Living communities, Assisted Livings, PCP, Out Patient, Palliative, Hospice, Private Duty A & B, guardians, specialists and families.
Home Health: 50% of health care dollars are spent in the last year of 5% of the population lives.
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.
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.