The thirty days after discharge are the dangerous part.

Discharge day sends her home with a folder, a new medication list that contradicts the old one, and instructions given to someone still groggy from a hospital stay. Then a follow-up appointment three weeks out, which she may not be able to get to.

A caregiver speaking with an older woman resting in bed while a family member sits nearby

Roughly one in five Medicare patients is readmitted within thirty days, and most of those readmissions trace back to that first fragile week.

What we do.

  1. 1A visit within 48 hours of discharge.Before the confusion compounds.
  2. 2We reconcile the medications against what is actually in the house.The discharge list and the cabinet almost never match. This is where we find the most errors.
  3. 3We read the discharge instructions with you.Out loud, in plain words, with questions welcome.
  4. 4We flag what to watch for.Specific to what she was in for.
  5. 5We tell her regular specialists what happened.They often do not know.

For discharge planners: we accept referrals seven days a week and make contact within one business day. Refer a patient

Common questions

How the care works

The ones that come up on nearly every first call.

Yes, that is the point of the model. Continuity catches the slow changes that a rotating roster misses.

A routine start takes a few days. A hospital discharge is faster, because the first week home carries the most risk.

Yes. We order home health, talk to the nurse directly, and make sure the two plans agree rather than contradict each other.

Still unsure? Call (872) 260-0204 and describe an average morning.

Get started

The next appointment doesn't have to be a production.

Tell us what is going on and we will tell you honestly whether we are the right fit. If we are not, we will say so.

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