Transitional Care Visits

Advanced Practice House Calls provide compassionate and expert medical care to our patients wherever they call home. 

 

Our nurse practitioners provide care to patients who meet the following criteria:

 

• Individuals with complex medical concerns but desire to be assessed by a mid-level provider in the comfort of their home.

• Individuals who are unable to visit a primary care provider in person due to a disability or chronic medical condition.

• Individuals who have recently been discharged from the hospital.

• Individuals affected by multiple medical conditions that cannot be evaluated thoroughly during a typical in-person visit.

 

Our process:

• Our NPs start with a health discovery to identify any primary and secondary medical issues.

• Once identified, we begin to address each condition individually to provide the most comprehensive health management plan.

• Once your health management plan is in place, we begin to utilize and or connect you with our resources of ancillary care, such as:

  • Nursing visits

  • Physical and occupational therapists

  • Home health organizations 

• We continually supervise Home Health services between visits and adjust the therapy to be customized to the patient

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Seamless Agency Coordination:

We bridge the gap between the hospital and the home. Our team partners directly with local Home Health agencies to oversee skilled nursing, physical therapy, and occupational therapy, ensuring all post-acute discharge instructions are followed to prevent avoidable readmissions.

Discharging case managers can receive updates for accepting, scheduling, and visiting the patient.