Hospital-Home Transition Care Program,Northern Virginia

Re-hospitalization is prevalent, extremely common among the chronically ill and elderly populations, and expensive to our health care system. The U.S. has an 18 percent rate of hospital re-admissions within 30 days of discharge and an alarming 76 percent of these are preventable, according to the Center for Technology and Aging.

Finding and receiving adequate follow-up care after a hospitalization is a challenge thousands of aging adults face every day. Patients encounter many obstacles while transitioning from a hospital  to becoming independent again in their homes. Often, these transitions are characterized by inadequate communication, omission of critical medications, inadequate discharge planning, and serious gaps in care during transfers to and from hospitals all leading to preventable declines in health status. These poor “hand-offs” are extremely common, especially for the chronically ill high-risk and frail older adult population. As a result, re-hospitalization is frequent and seemingly inevitable for these patients.

Our Hospital Transitional Care Program  provides comprehensive in-hospital or Nursing care facility planning and home  care follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions.

    The Transition Program  is developed to

  • Prevent avoidable hospital re-admission and emergency room visits for primary and co-existing conditions by addressing the negative effects associated with common breakdowns in care when older adults with complex needs transition from an acute or sub-acute care setting to the home.
  • Enhance patient and family caregiver satisfaction by Preparing and assisting patients and family to more effectively manage changes in health associated with multiple chronic illnesses.
  • Improve in health outcomes after discharge. Holistic Improvements in physical health, functional status, and quality of life.

This is accomplished through early identification of patients’ goals, development and implementation of individualized plans of care, application of effective communication, and the adoption of evidence-based  home health care.

    The Hospital to Home Transition program is currently available for :

  • Chronically ill high-risk older adults with multiple chronic medical conditions
  • Multiple Medications/Complex therapeutic care
  • Resident of Northern Virginia
  • Discharged to home from a hospital or brief Skilled care Nursing Home/Rehab facility

For clients who suffer from multiple chronic conditions and complex therapeutic regimens, our Transition Care Program emphasizes coordination and continuity of care, prevention and avoidance of complications, close clinical treatment and management and re-hospitalizations – all accomplished through well organized and planned transition in home care program with a physician oversight.

The Transition Program is a multidisciplinary model that includes House Call physicians, nurses, social workers, discharge planners, Clinical pharmacists and other members of the health care team in the implementation of tested protocols with a unique focus on increasing patients’ and caregivers’ ability to manage their care.

Our Transition Care Program includes the following essential elements:

    The team consists of House call Board certified Physician, RN, LPNs, Social worker and certified nursing assistants-In-hospital  preparation, and development of an evidenced-based plan of care;

    – Physician-nurse-social worker designed comprehensive care plan

    – In-Home Care Assistance for Activities of Daily living by Certified Nursing Assistance

    – Regular home visits by the team members with available, ongoing documented telephone support through an average of One month post-discharge;

    – Comprehensive, holistic focus on each patient’s needs including the reason for the primary hospitalization as well as other complicating or coexisting events;

    – Active engagement of patients and their family and caregivers including education and support;

    – Emphasis on early identification and response to health care risks and symptoms to achieve longer term positive outcomes and avoid adverse and untoward events that lead to re-admissions;

How Does Transition Care Program work ?

The Hospital Transitional Care Program targets older adults with two or more risk factors, including history of recent hospitalizations, multiple chronic conditions or on multiple medications and Poor Functional Status requiring Care Givers Assistance.

– Each Client will be assigned a Care Giver to assisted with Activities of daily Living ( ADLs)

– In the home within same day of discharge from the hospital or Skilled care facility

– At least semi-monthly by Registered Nurse through the duration of the intervention;

– Seen by the assigned House call Physician Within 24 hrs of discharged;

– Additionally, Case manger RN:

– Maintain daily telephone availability in order to respond to patients’ and caregivers’ needs and concerns;

– Provide patients and caregivers with a written plan with instructions and phone numbers of the assigned house call physician, and ambulance services for emergency care; and

– Initiate telephone contact with a patient during any week that a patient is not visited at home.

Trained Caregivers are assigned to the case.

After patients are discharged from a hospital stay, they are assisted in the home by caregivers (few hrs/day or Live-In depending on the needs) who can provide them with medication pick-up and reminders, assist with activities of daily living, household duties to keep their homes safe and clean and light homemaking and meal preparation. Caregivers also serve as the eyes and ears for family members and other loved ones to alert either doctors or family members if any notable situations arise.

All Care Givers are thoroughly screened, extensively trained, insured and bonded, matched to your preferences, professional and reliable.

American Care Partners @ Home is also an approved Service Provider (Private duty nursing, Respite care, Personal Care Services) for Various Virginia Medicaid Waiver Recipients Including:

LPNs and/or RNs are assigned as direct care givers for Patients with advanced and complex medical conditions (including those with In-home ventilator, tracheostomy, or on complex therapeutic regimens etc..)


Let us help you or your loved ones, live safe and comfortable at home!
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