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Hospital-Home Transition Care Program, Northern Virginia

Hospital-Home Transition Care Program, Northern Virginia

Re-hospitalization is prevalent, extremely common among the chronically ill and elderly populations, and expensive to our health care system. The U.S. has an 18 percent rate of hospital re-admissions within 30 days of discharge and an alarming 76 percent of these are preventable, according to the Center for Technology and Aging.

Finding and receiving adequate follow-up care after a hospitalization is a challenge thousands of aging adults face every day. Patients encounter many obstacles while transitioning from a hospital to becoming independent again in their homes. Often, these transitions are characterized by inadequate communication, omission of critical medications, inadequate discharge planning, and serious gaps in care during transfers to and from hospitals all leading to preventable declines in health status. These poor “hand-offs” are extremely common, especially for the chronically ill high-risk and frail older adult population. As a result, re-hospitalization is frequent and seemingly inevitable for these patients.

The Hospital to Home Transition program is currently available for:

  • Chronically ill high-risk older adults with multiple chronic medical conditions
  • Multiple Medications/Complex therapeutic care
  • Resident of Northern Virginia
  • Discharged to home from a hospital or brief Skilled care Nursing Home/Rehab facility

The Transition Program is a multidisciplinary model that includes House Call physicians, nurses, social workers, discharge planners, Clinical pharmacists and other members of the health care team in the implementation of tested protocols with a unique focus on increasing patients’ and caregivers’ ability to manage their care.

Our Transition Care Program includes the following essential elements:

The team consists of House call Board certified Physician, RN, LPNs, Social worker and certified nursing assistants-In-hospital preparation, and development of an evidenced-based plan of care;

Physician-nurse-social worker designed comprehensive care plan including:

– In-Home Care Assistance for Activities of Daily living by Certified Nursing Assistance

– Regular home visits by the team members with available, ongoing documented telephone support through an average of One month post-discharge;

– Comprehensive, holistic focus on each patient’s needs including the reason for the primary hospitalization as well as other complicating or coexisting events;

– Active engagement of patients and their family and caregivers including education and support;

– Emphasis on early identification and response to health care risks and symptoms to achieve longer-term positive outcomes and avoid adverse and untoward events that lead to re-admissions;

Let us help you or your loved ones, live safe and comfortable at home!

Call us today 703-532-4357  for Free ! No Obligation Consultation.