The patient, PCP and the acute care facility by providing a teamwork approach through:
- Continuity of care, by assisting patient reconnect
with their PCP in a timely manner
- Access to a robust network of area
- Reducing emergency room visits
- Improving outcomes by
seeing the patient
within 48 hours of discharge to ensure
- Personalized quality
care in the home
A licensed medical provider performs a medical evaluation (and treatment if necessary) in the patients’ home for those who need medical management of various chronic or acute illnesses. In addition, Medicare patients who have been discharged from an inpatient setting typically are at risk of their medical condition deteriorating quickly due to lack of available resources or patient education. A medical exam in the patients home within 48 hours of the patient’s discharge from an inpatient setting is to ensure the patients’ medical stability and medication education as well as continuum of care coordination back to their community Primary Care Physician (PCP).
The Patients served by Transitions House Calls (THC) include those who have recently discharged from an inpatient setting such as hospital, Long Term Acute Care (LTAC), Nursing Home, or Rehabilitation hospital. In addition we are able to serve patients who reside in retirement communities, assisted living facilities or single home residences. These patients often have difficulty obtaining transportation to an area clinic therefore Transitions House Calls affords access to their own personal medical team in the patients’ home.
Transitions House Calls is not “Home Health Care”, rather THC works in conjunction WITH area home health agencies when it is deemed clinically appropriate.