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Transitional Care Programs and Services


Transitional Care Programs and Services

Intensive Post-Acute Rehabilitation

Individuals entering rehabilitation are always unique, but their primary objective is typically the same – a return to health, home and what’s important in life, as soon as possible. At Touchpoints Rehab we understand.

Our innovative, personalized program is designed to accelerate the recovery process, so that patients can Get Well, Live Well and Be Well, faster, better and with fewer challenges than any traditional rehabilitation program. These programs are designed to optimize therapy, promote recovery, and provide ongoing quality of life for patients experiencing chronic and high acuity medical conditions. 

What is Transitional Care?

Touchpoints Rehab is a leader in this field. Transitional Care uses a team of healthcare providers including nursing, respiratory and other staff to closely monitor a patient’s health status from setting to setting. This team will guide care from the hospital to the skilled nursing facility and into the home ensuring a smooth transition from one to the next. You will often see the same nurse or team member in the hospital, in the facility and following up after discharge to ensure success and avoid readmission to the hospital.

The Care Transitions team works with physician guidance and alongside APRNs, Physician’s Assistants and the entire staff of the skilled nursing facility. The team focuses additional focus and resources on patients with complicated medical conditions who are at risk for frequent hospital admission.

Care Transitions Team

  • Care Transitions Nurse Liaisons
  • Care Transitions Respiratory Therapist
  • Multi-disciplinary clinical team
  • Consulting physician specialists, PAs and APRNs

Addressing Frequent Hospitalizations

The program also addresses repeat hospitalizations by applying frequent lab work and assessment, integrated specialty care including pulmonary/respiratory therapy and sleep medicine, specialist consultation, clinical partnerships and more.

For patients with multiple hospitalizations the team will address their general state of health and wellness and improve their daily functionality. This will get them back home where they want to be and slow the tide of re-hospitalizations.
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Care Transitions Clinical Programs

Program Highlights

Some patients who have been hospitalized following these conditions may be encouraged to stay in a post-acute facility to regain their strength. Our network partnerships ensure that our patients receive rehabilitation services in close collaboration with their medical team within the hospital networks. The key features of this unique approach include: 

  • The Touchpoints Rehab team has been trained by the hospital network team. The clinical team follows their established protocols.
  • Touchpoints Rehab has experienced physicians and physician extenders.
  • The Touchpoints Rehab team includes a dedicated Director of Care Transitions who follows caseload patients through the course of their care, including after discharge home and provides additional, continuous clinical over- sight and support. 
  • The hospital and Touchpoints Rehab teams remain in continuous communication, working together to ensure a smooth transition. In addition, the hospital team remains informed on the progress of patients’ post-acute stays on a daily basis and continuing through discharge home. 
  • Once discharged, patients are reconnected with their primary care provider.
  • Touchpoints Rehab staff are skilled in the delivery of all IV treatments and modalities.  

Program Benefits

  • Consultations and daily communication with the hospital team ensure continuity of care and optimal treatment decisions.
  • Careful oversight of progress and a quieter, more personal environment are highly conducive to rapid improvements.
  • Individually paced rehab programming enables faster recovery, stabilization and restoration of strength.
  • Ongoing specialty evaluations
  • Diagnosis-specific education for you and your family
  • Healthy menus tailored to your diagnosis.
  • Weight monitoring
  • Physical, occupational and speech therapies
  • Customized care planning
  • Home support and discharge planning
  • Weekly rounds by hospital practitioners
  • IV Lasix, Bumex and Milrinone therapies
  • Weekly lab value monitoring
  • Touchpoints Rehab locations in Bloomfield, Manchester, East Windsor and Farmington.

For more information, please call (860) 812-0788 or visit us online at www.touchpointsrehab.com

 

News & Updates

Discover the latest from our blog

  • Residents of Trinity Hill Care Center took part in an NFL Fantasy Draft Party with special guest, former New England Patriot, and New Britain native, Tebucky Jones! Residents ate football season fare while they built their fantasy teams.  Each resident who participated in the draft will be able to track the progress of their fantasy team during their stay and throughout the NFL regular season. The resident with the most points at the end of the season will win an NFL gift basket.
  • On September 4th Chelsea Place Care Center held a pep rally type event, the second annual of its kind for iCare, at the care center in Hartford. iCare Health Network and all its care centers made the commitment to provide a Stigma Free environment and Stigma-Free care to residents with mental illness as well as those with substance use disorder, dementia and cognitive disorders in 2018.
  • iCare Health Network will be holding an all day RN Hiring Event on September 11, 2019 at the corporate office in Manchester for opportunities throughout the Network. Interviews will be conducted on the spot, if so desired. Every person hired will be entered to win an Apple iPad. Every attendee will be entered into a drawing to win a door prize. Check out the full post by clicking or go to icare.careers. 
  • 60 West's Busy Summer

    August 29, 2019

    Thanks to the excellent work of the life enrichment staff, the 60 West residents and staff were busy all Summer with activities. The Summer was kicked off with a Christmas in June event, followed by partnerships with and donations to Hands on Hartford, cultural travel luncheons and decorating the patio garden. 
  • The Touchpoints at Bloomfield Food Services team participated in Windsor Senior Center’s Summer Celebration on August 15th.  Said Food Services Director Paul DeMaida, ”We prepared breakfast for 75 here at the facility and then delivered it to the senior center where we stayed to serve the local seniors. It was well received and we had a great time doing it.”  The staff that participated were Paul DeMaida, Brandon Williams (a cook), and dietary aides Jeanita Brown and Marle…
  • The staff and residents of Touchpoints at Bloomfield had an outstanding time dunking the “shark”, Administrator Jaime Faucher. Staff and residents participated in throwing the bean bags into the sharks mouth. If they hit the target Jaime the Shark was “dunked” with very cold water by Recreation Director Cindy Payne. The week included a visit from a shark expert who spoke on a shark’s day to day life, made shark teeth necklaces and of course watched the popular 1970’s film Jaws.  
  • Three veterans who are current residents at Silver Springs Care Center in Meriden took part in an equine therapy program through Manes and Motions, a Therapeutic Riding Center operated by Hospital for Special Care in New Britain. According to the Manes website, “riding a horse gives you freedom and empowerment through movement. A horse can be a powerful motivator in reviewing or reinforcing many behavioral, physical, mental, social and emotional goals.”
  • On August 10, 2019, staff and their families represented iCare at the 2019 West Indian Independence Celebration and Parade in Hartford. The iCare team marched in the parade from Main and Battles Street, ending in Bushnell Park, decked out in matching t-shirts with a One Love theme.