We are not home health and we are not trying to replace your primary care physician, but we work with them to make sure that our patients have the utmost care. Services we provide:
Our nurse practitioners provide in-home visits for post-acute Transitional Care, chronic care, and palliative care. We are on call after hours and weekends and can act as PCP or coordinate with your current PCP and spe
cialists.
• Patient phone contact within 48hr of DC
• NP visit at their residence with 7 days of discharge
• Refill and adjust
prescriptions
• Risk assessment at initial visit to determine risk of readmission and frequency of follow up visits
• Coordination of care and communication with home health, PCP, specialists.
• Thorough review of hospital and facility records with follow up on labs/diagnostics/orders. Records left for PCP f/u appt.
• Additional visits only as clinically indicated to prevent readmissions based on risk assessment.
• Education of the patient and family on the diagnoses, disease processes, medications, follow up appointments, and discharge instructions
• Assistance with coordinating readmission to the acute care/rehab system if indicated with 30 days DC
• Referrals of patients from the home to our partner facilities
Insurance we take:
We take Medicare and most major insurances.
