When you or a loved one has spent time in a nursing home, rehabilitation center, or hospital and are preparing to return home, the discharge process is critical. Discharge planning takes place when the medical and/or administrative staff of the facility meets with the patient and their family to discuss what needs to happen at home to ensure the best outcome when they return home. Medical HouseCalls refers to this as Transitional Care, which can be tailored to any individual who needs assistance.

Transitional care is defined as a broad range of time-limited services designed to ensure health care continuity and promote the safe transfer of patients from one level of care to another, or from one type of setting to another. These transitions are a particularly vulnerable point for a patient. Medical HouseCalls is able to help relieve some of the stress that comes with such a transitions. We make sure that the medical facility discharge instructions are followed explicitly for the best outcomes and to help reduce the risk of complications or re-hospitalizations. To do this Medical HouseCalls makes the facility’s discharge plan part of the home care plan we develop with you or your loved one.

Depending on the situation, you may have days, weeks, or months to plan for this time of transition when you or your loved one is discharged from the hospital, rehabilitation center, or other care facility. Whenever it is that you begin to think about what is needed and whether home care is the answer, contact us at Medical HouseCalls. We can assist you with your discharge planning and develop a customized home care plan to support the transition home. We will review the requirements in the discharge documents, and work with you or your loved one to develop a customized care plan that meets the unique needs of our patient. This care plan will consider medical conditions, physical limitations, cognitive issues, and the personal preferences of you or your loved ones. Some of the tasks in the care plan will come from the discharge instructions and some will come from the home care assessment we conduct.

Medical HouseCalls is able to see you or your loved one within 7 business days of the release back to your primary residence.