The key goals of the "Home to Stay - Transitional Care Plan are:
- Assist patient and family members with a supportive transition when they are being discharged from the hospital and returning to their home.
- Provide a customized level of skilled home care and support based on the individual needs of each patient.
- Decrease need for the patient to have to return to the hospital.
The services of the Transitional Care Plan are:
- A VNA Health System Nurse Liaison will coordinate with your hospital case manager or social worker in processing all the information needed for admission to home care.
- Detailed reveiw of hospital discharge instructions assessing the need for support systems and community care involvement.
- Creating a personalized Care Plan based on the patient's specifc diagnosis and home environment.
- Increased visits upon admission to home care to assure medication accuracy, begin education and follow-up care with phone/telehealth monitoring as neccessary.
- Establishing relationship with family for education and health condition updates, as approved by patient.
- Assistance in scheduling follow-up appointments with Primary Care Physician/Surgeon.
- Conducting an extensive medication review with written and verbal instructions as necessary.
- Ongoing monitoring of patient psychosocial health in coordination with social and psych nurse as necessary.
- Consistent availability-VNA Nursing Staff available 24 hours/7 days per week for any questions or concerns.