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"I want to go/stay home"


Transition of Care

Do you have a loved one that is transitioning from a healthcare facility to home and you need assistance understanding what care will be needed or where you can find reliable care? Below is a sample transition of care package to ensure a safe homecoming with individualized follow-up care for a both short term and long term as the need requires. Needs/Cost can be customized as to desires of patient.

Transition Care Package       $850.00

Please purchase package 48 hours prior to anticipated discharge. If possible planning for a return to home should begin on admission to any facility (hospital, rehab, skilled care…)

Services included:

  1. RN to speak directly with the discharging facility at least the day prior to discharge, and a follow up call at time of discharge to cover any changes (this requires a signed consent for our RN to obtain health information and discharge instructions)
  2. Four hours of a Care provider services at time of discharge (on day of discharge)
    1. Personal Care Provider and RN to have conversation to define expectations and personalized needs of patient/ family
    2. Personal Care Provider to get patient settled at home. (basic house cleaning, laundry, meal, review discharge instructions for clarity with the patient)
    3. Personal Care Provider to complete needed shopping as requested to ensure patient has necessary medications (as ordered by physician), food, supplies for basic ADL’s (activities daily living)
    4. Personal Care Provider to assist patient with personal needs
    5. Personal Care Provider available to interface with any other services in the home to ensure coordination of care to maximize outcomes
    6. Personal Care Provider to provide social and emotional support as desired by patient
  3. Registered Nurse to visit within 24 hours of discharge home to complete medication review and education. RN will work with patient and family to develop a plan for the 4 weeks of follow up care and for ongoing care if needed to keep them at home long term. (this may require family participation if patient unable to make independent decisions)
  4. Certified Home Health Assistant, under the direction of a Registered Nurse will visit one day a week for 4 hours per visit for 4 weeks post discharge to follow the plan of care developed by the RN, Patient and Family (written copy to be left in home)
  5. Phone access to a Registered Nurse 24/7 for 28 days after discharge
    1. Call (989) 205-0511 anytime, as often as you need with any healthcare related questions or need for changes to plan of care
  6. RN to develop long term care plan with patient, family and physician as necessary. Long term plan will be defined and in place by the end of week 2 post discharge.
Its The Right Thing To Do



Questions - Confused


ADVOCACY PACKAGES

Personal Annual Plan- “phone a nurse with questions”       $350 annually
  • This service is paid by an individual on an annual basis
  • Registered Nurse available to answer healthcare related questions such as but not limited to:
    • I am having these symptoms- “what should I do”
    • I have a new medication- “what do I need to know about this med”
    • My parent is getting older “what do I need to know and how can I plan for what is coming next”
    • I don’t have a doctor but I need one- “how do I find a doctor”
    • My family member/myself is in the hospital and I have no idea what is going on- HELP!
Employer Plan- “phone a nurse with questions”       $TBD
  • This service is paid by the employer as part of the benefit package
  • Rate is available to the employer if all employees are provided the service on an annual basis and rate is determined by number of employees to be included in package
  • Registered Nurse to answer healthcare related questions such as but not limited to:
    • I am having these symptoms- “what should I do”
    • I have a new medication- “what do I need to know about this med”
    • My parent is getting older “what do I need to know and how can I plan for what is coming next”
    • I don’t have a doctor but I need one- “how do I find a doctor”
    • My family member/myself is in the hospital and I have no idea what is going on- HELP!
Its The Right Thing To Do