Our strategy is research-driven and theory-based, and we strive for continual improvement through evaluation. Our measures are consistent with national standards and we are working towards NCQA accreditation (http://www.ncqa.org/).
Our registered nurses coordinate care of clients across healthcare settings, working closely with the patient, their family caregivers, and providers to implement a care plan that will promote positive health and cost outcomes. Our nurses will meet with patients prior to discharge to enlist participation, clarify discharge instructions, conduct medication reconciliation and review follow-up care plans.
Once home, our experienced staff will call clients as an initial follow-up within 72 hours of discharge. The call verifies the care plan, home health services, and follow-up appointments are in place. For a period up to two months, we will work closely with our clients and their primary care doctor to ensure they attend scheduled office visits and lab testing. Our home visits and regular phone/video support serve as reminders and motivators to help client’s stay on track. This allows our nurses and educated clients to detect changes in health and intervene early enough to avert serious health problems that could land them back in the emergency room.