"Guiding You through Transitions with Compassionate Care"
Steps in Transitioning
Transition Planning:
We create a customized transitional plan tailored to your specific requirements. This plan includes: Nurse Practitioner collaboration for a minimum of 30 days after hospital discharge. Visiting the client once a week or more depending on acuity, alongside Home Health Care and speciality care physicians. Our goal is to assist with stabilization and prevent re-hospitalization by assessing and diagnosing acute developments timely.
Medical Support:
Our healthcare professionals provide ongoing medical support including: identifying acute findings, medical management, follow up labs and rehabilitation services. We ensure that your healthcare needs are met during the transition period and beyond.
Follow-up and Monitoring:
We maintain regular communication and follow-up visits to ensure your well-being and address any concerns or issues that may arise during the transition process. We monitor your progress and make adjustments to the plan as needed.
Care Coordination:
Our experienced team works closely with hospital staff and your healthcare providers to ensure a seamless transition. We coordinate appointments, gather necessary medical records, and communicate with all parties involved.
Education and Training:
We provide education and training to empower you and your caregivers with the knowledge and skills necessary for a smooth transition. This may include information on self-care, medication management, and navigating community resources.
Personalized Assessment:
We conduct a comprehensive assessment of your needs, taking into account your medical condition, support system, and individual preferences.
Emotional Support:
We understand that transitioning from the hospital to your home or a new facility can be emotionally challenging. Our team offers emotional support, counseling, and resources to help you and your family adjust to the changes
Goal:
Our goal (ACCN) is to ensure a seamless and comfortable transition from the hospital to your home or to an assistant living/rehab/transitional facility, providing the necessary support and care to help you regain independence and achieve a successful recovery.
