For Discharge Planners

Medical Team Meeting With Senior Couple In Hospital Room

It’s your job to be sure that patients are discharged to a home situation that can readily handle their care needs. We provide the necessary in-home support to ease transitions and reduce 30-day readmission.

Refer a patient when

  • you have concerns that the home situation is not robust enough to handle the increased needs of a frail or recently discharged patient. Relatives may live far away. A spouse may have his or her own health challenges. We can assess the situation and put safeguards in place to safely ease the transition.
  • medication management is an issue. Especially if the patient is struggling with memory problems, our trained staff can implement strategies to improve adherence and help patients (and families) adjust to new regimens.
  • daily monitoring could prevent a problem. We can be your eyes and ears. Our caregivers can take daily weights and vitals, catching a problem early, before it results in an emergency room visit.