How can you achieve a safe transition from post-acute care to home?
When you choose HCF for your rehabilitation needs, you have the option of a seamless transition home from many of our care communities with our professional home health staff. The HCF Transition of Care program is highly comprehensive and provides our patients a smoother transition back to their home environment. HCF is committed to patient results and satisfaction and our Transition of Care program is an integral part of achieving that commitment.
Many patients enter post-acute care with a lot of questions about what their stay is like and how they will meet their goal of returning to the home setting. Our goal is to support patients through smooth transitions, continuity of care, and reduced hospital readmissions. We work with each member of our care community team to ensure that your stay meets your recovery goals and that it is well coordinated with us as well as with your physicians.
Care Plan Coordination
To facilitate the transition of care plan, we will conduct a care conference with you and/ or your family soon after your admission to our care communities. During this conference, our transitional care team will ask you about your goals, your return to home, and any obstacles that might prevent you from achieving your goals. The team will outline your stay and discuss making arrangements for a scheduled pre-home evaluation and what changes or equipment might be needed to allow a safe return to your home. After a plan has been established, our staff will ensure that your designated Primary Care Physician is notified of your stay. We know that physician involvement is important to patients and is imperative in ensuring successful transitions of care.
In preparation for returning home, a member of our therapy team will address any other home modifications that may be necessary to allow for a safe transition. Prior to leaving your inpatient stay, we will assist in making any necessary physician follow-up services, arrangements for durable medical equipment, as well as ensure that prescriptions for necessary medications are addressed. Upon discharge, we will transition you to the care of our home health team. The goal of home health is to promote and maintain health after being discharged from the nursing facility, through the utilization of experienced medical professionals and support services. In addition, a summary of your inpatient stay, will be provided to your designated primary care physician.
Our goal at HCF is to ensure that you receive the best possible care and are able to return to your home if that is your desire. If you have any questions or concerns during this process, we encourage you to talk to a member of our dedicated staff. We are grateful to be a part of your recovery!