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, part of the iCare Health Network, 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
- Heart Failure Nurse
- Regional Clinical Director
- 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
- Congestive Heart Failure
- Chronic Obstructive Pumonary Disease (COPD) and other related pulmonary disease processes.
- Post open-heart surgery care.
- Affiliation or enrollment in Accountable Care Organization, Risk or Payment Bundle and/or at high risk for readmission.
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.
- 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, Dobutamine 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, email moc.nheraci@ofni or visit us online at www.touchpointsrehab.com
News & Updates
Discover the latest from our blog
On February 6, 2024, as part of Black History Month, the team at Touchpoints at Chestnut celebrated the life of music legend Bob Marley. Staff and residents enjoyed listening to his music and shared Jamaican beef patties and cocoa bread. February 6th is Bob Marley Day. Nesta Robert “Bob” Marley was born February 6, 1945 in Nine Mile, Jamaica. He emerged as the single most influential reggae musician of all time and is closely associated with Jamaican national identity and Rastafarian …
Touchpoints at Manchester Goes Red for American Heart Month
February 2, 2024February is designated as American Heart Month to bring attention and awareness to the prevalence and severity of heart disease in the United States. Touchpoints at Manchester staff and residents wore red on February 2, 2024 for National Wear Red Day which is held the first Friday of every February to help raise awareness around heart disease.
iCare Health Network Celebrates its Activities and Therapeutic Recreation Professionals, 2024
January 22, 2024January 22-28 is National Activities Professional Week with a theme of “Innovate, Inspire, Involve”. On this week we celebrate all of iCare’s Therapeutic Recreation, Life Enrichment and Activities Professionals as they bring fun, engagement, enrichment and fulfillment to our residents’ lives.
Last week the staff and residents at Touchpoints at Manchester were treated to a performance by a special guest, Mr. Elvis Presley. Well, Elvis times two, really. Straight from the gates of Graceland, the King and the other King dropped by to celebrate his own birthday, January 8th. The Elvises (Elvi?) made their way through the resident care units, driving the crowds wild with their dancing and playing all the hits. It appears these particular Elvi showed up from the early 1970’s. Much to …
Celebrating the Ongoing Impact and Important Contributions of Dr. Martin Luther King, Jr.
January 15, 2024There are so many deep and meaningful quotes attributed to Dr. Martin Luther King, Jr. that resonate strongly for those in healthcare and in daily service to others. In years past, iCare shared a post with some of Dr. King’s eloquent and meaningful quotes and facts about King. One quote that speaks so directly to our current times is, “We may have all come on different ships, but we are in the same boat now.”
iCare Health Network Christmas Lobby Contest Photo Gallery, 2023
December 13, 2023On December 12, 2023 members of the iCare leadership team toured eleven iCare Health Network care centers to experience the Christmas joy on display in their respective lobbies as part of the annual lobby decorating contest. The care center teams came through as always with music, food, staff and resident involvement, skits and all sorts of decorations and goodies. Great job to all of the iCare center teams on making this is a great success and bringing joy to residents and staff this time of…
Touchpoints at Bloomfield Hosts Thanksgiving Luncheon 2023 at Bloomfield Senior Center
November 17, 2023On November 16, 2023 the team at Touchpoints at Bloomfield once again hosted a Thanksgiving luncheon at the Bloomfield Senior Center. About 75 Bloomfield seniors were in attendance as several department managers from Touchpoints at Bloomfield served a traditional holiday meal complete with appetizers, dessert and apple cider. Great job, TAB team!
With Deep Gratitude for Your Service, Happy Veterans Day 2023
November 11, 2023On 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. We celebrate the service of our Veterans with gatherings and group recognitions and celebrate their service and their sacrifice. Check back in as we update with the day’s events.