Trained and Ready

For clients who have advanced care needs, such as those with complex chronic illness, serious illness, or need assistance with three or more activities of daily living:

Comprehensive Care Management

Our goal is to keep you at home where you want to be and avoid any undesired visits to the emergency department or hospitalization. We are able to accomplish this by offering:

• A comprehensive care plan  

  • Track and follow up on all physician visits.

  • Ongoing medication reconciliation as medications change.

  • Routine communication with families to keep them abreast of care needs and any changes.

• Two (2) nursing assessments each month

  • Any findings which are of concern will be reported to the client’s physician and family.

• Should a hospitalization occur, we will visit our clients in the hospital or skilled nursing facility as needed to aid with discharge planning, ensuring a seamless transition back home.

Care Transitions

We understand the challenges seniors face when making the transition from hospital to home or skilled nursing facility to home and the risk of being readmitted back to the hospital without the proper supports in place. We offer the following to ensure once discharged clients are able to stay at home without fear of readmitting to the hospital:

• A one-time nurse visit at home after being discharged from the hospital or skilled nursing facility.

  • Occurs within 24 hours of hospital or skilled nursing facility discharge

• Medication pick up from the pharmacy

• Medication reconciliation once at home to ensure the client is taking the right medications at the right time - this is the most common reason for readmission to the hospital.

• Assessment of home/client safety

  • Can be arranged prior to discharge home​

• Review discharge instructions and facilitate any additional referrals which may be necessary to keep client in their home