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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

  • As a kick-off to the holiday season and to show appreciation to its hard working employees, the team at Chelsea Place Care Center held a Spirit Week November 14-20th.  The Week included, as it always does at Chelsea Place, plenty of music, dancing, food and fun. The different theme days included Twin Day, Sports Day, Crazy Hair or Hat Day, Throwback Thursday and more.  Nice work, Chelsea team!
  • To celebrate its hardworking staff, the team at Touchpoints at Chestnut threw an Employee Appreciation Day. No better way to show appreciation than serving some delicious food. The spread was mainly East Indian cuisine prepared by Dunns River, a Jamaican Restaurant in Hartford. The event was a big success and an excellent way to kick off the upcoming Thanksgiving Holiday. Chestnut’s Dwayne Mullings, Cori Knutsen and Jennifer Oliveira served the staff.
  • During the month of November, the home care and hospice community honors the millions of nurses, home care aides, therapists, and social workers who make a remarkable difference for the patients and families they serve. These heroic caregivers play a central role in our health care system and in homes across the nation. According to the National Association for Home Care & Hospice (NAHC) website, to recognize their efforts, we call upon all Americans to commemorate the power of caring, both…
  • On the November 16 episode of PBS NewsHour, 60 West was featured and profiled in a segment titled “America’s prison population is aging, but care options for older parolees remain limited.”  The segment featured two residents describing how 60 West has impacted their lives and Administrator Jessica DeRing detailing the impact of the care center’s mission on individuals and public policy.
  • On November 11, 2021 the team at Touchpoints at Manchester took a moment to celebrate a big achievement: the care center’s return to Five Star designation with the Centers for Medicare and Medicaid Services (CMS)! According to the CMS website, CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily and to help identify areas about which they want to ask questions. The Nursing Home Compare Web site features a q…
  • Celebrations of service, gatherings and group recognitions are beginning to reemerge and are more important than ever. This is especially true when the purpose is to celebrate our nation’s Veterans, their service and their sacrifice. On behalf of iCare Health Network, our care centers and entire staff, we would like to honor all of our nation’s veteran’s for all that they gave in service of our country.  There are dozens of veterans in every iCare facility as staff members, re…
  • Fresh River celebrated ten Veterans with a celebratory breakfast and speech proclamation to thank them for their services. Rosanne, our recreation director, put this all together, and our creative Dietary manager cooked them a wonderful breakfast. We were lucky enough to have our First Selectman, Jason Bowsza, to not only come and show appreciation to our veterans, but to present them with personalized certificates for their services in the Army, Navy, Air Force, and Marines. Their true spirits…
  • On November 5, 2021, Silver Springs’ Lynn Webster, RN, retired from Silver Springs and iCare Health Network after 41 years of service. Lynn began her career at Silver Springs in May of 1980 in the dietary department. She worked in various roles throughout the center, including as a charge nurse, nursing Supervisor and several years, up until her retirement, as a Regional Nurse Liaison.  Lynn was recognized in May of this year as a winner of the Nightingale Award for Excellence in Nursing …