Transitional Care copy

Finding new strategies to reduce hospital readmission rates and emergency room visits is a common theme among hospitals, payers and patients. About 20% of all Medicare beneficiaries discharged from hospitals return to the hospital within 30 days. The main reasons for this are inadequate follow up, lack of education, patient non-compliance, incomplete transfer of information, poor communication and the absence of a single point person to ensure continuity of care.

Osler at Home’s discharge planning team will become your single point contact and coordinator. This team, which includes your Primary Care Physician, nurses, nurse practitioners, social workers and case managers will work together, along with the patient’s family or caregivers, to arrange for their transition out of the hospital to their post hospitalization recovery. This process often may begin before hospitalization or soon after admission.

Key Program Featureshome care

  • Overall Care Plan and Risk Profile
  • Pre-discharge assessments
  • Home Safety Evaluation
  • Coordination of follow-up appointments
  • Caregiver support and education
  • Medication reconciliation and management
  • Cognitive and Behavioral Health Screening
  • Self-care and Motivation assessment
  • Identification of medical equipment and supplies needed for care
  • Coordinate community resources.