The Transitional Care program provide services to patients with chronic diseases such as Heart Failure, Chronic Obstructive Pulmonary disease, Diabetes, uncontrolled Hypertension, whose medical and/or psychosocial problems require moderate or high-complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), to the patient s community setting (home, and or assisted living). The Team follow up with patients 18 years old and over within 24 to 72 hours after discharged home.
The Nurse practitioner will gather these patients daily and sample them on a daily patient log, review patient s history and physical/ consults. Assess inpatient and family understanding of their disease, educate and collaborate needs with the Care Transition Team.
The APN is also responsible for the following:
Communicate with home health agencies and other community services utilized by the patient and/or family/caretaker. Organizing and arranging referrals of needed community resources.
Educate patient/ family/ guardian, and/or caregiver to support self-management, independent living, and activities of daily living.
Support for Medication management and other treatment regimen adherence, Identification of available community and health resources
Facilitating access to care and services needed by the patient and/or family
Obtaining and reviewing the discharge information (e.g., discharge summary and medication reconciliation)
Reviewing need for, or follow-up on treatments
Interaction with other qualified health care professionals who will assume the care of the patient after discharge by assisting in scheduling any required follow-up with patients with their providers and community services.
Home visits are required.