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

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.

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

"When I needed rehab after my open heart surgery Touchpoints was my only choice"

February 11, 2019

“My family have been fans of Touchpoints at Manchester for many years, so when I needed rehab after my open heart surgery Touchpoints was my only choice. I experienced many complications but the amazing nurses and therapists were on top of things every step of the way…I am so surprised that I am going home so soon after all I have been through. My family and I feel confident that I am ready, and we all have the education and services I need to continue my recovery.”
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Regina Estrada, Certified Dementia Practitioner of the Year, Pictured on Times Square Billboard

February 6, 2019

Silver Springs’ Charge Nurse Regina Estrada won Certified Dementia Practitioner of the Year in 2018, as awarded by the National Council of Certified Dementia Practitioners (NCCDP). See the original blog post here… On February 5th a picture of Regina posing with her certificate and NCCDP’s Lynn Biot-Gordon, COO, and Rhonda Branda, President, appeared in the famous digital billboards of Times Square, New York, New York.
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Westside Care Center is Ready for the Super Bowl

February 1, 2019

Westside Care Center is already in the Super Bowl spirit with a few days left to go. On Friday, February 1st the Westside team wore their Patriots jerseys to celebrate their New England team. Sunday’s Super Bowl bash for residents will include pizza, wings and a homemade cake made by Theresa in Food Service.
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Park Place Health Center Joins the iCare Health Network Under the Name Parkville Care Center

January 29, 2019

On January 25, 2019, iCare Health Network assumed operation of Park Place Health Center on Greenwood Street in Hartford. The 150-bed skilled nursing care center will emerge and operate under the name “Parkville Care Center” as recognition of its important place and history in the Parkville neighborhood of Hartford. Park Place has played a vital role in skilled nursing and long-term care for the City and region, especially for the Hispanic population it has historically served.
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Silver Springs Care Center Celebrates an Employee Safety Milestone

January 25, 2019

Silver Springs Care Center team celebrated a key milestone in employee safety; 750 days without time lost to a work related injury. For all of their hard work, attention to safety and dedication to a team effort, the each shift was treated to a Pizza Party complete with wings and salad. Once the party was scheduled Silver Springs had already crossed through 780 days without lost time!
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Touchpoints Rehab's CHF Program to be featured on Fox61's 'Northeast Living' with Rachel Lutzker

January 23, 2019

Fox 61’s Rachel Lutzker filmed a segment for Northeast Living featuring Touchpoints Rehab’s signature Congestive Heart Failure rehabilitation program. The clip will air on Valentine’s Day and will include an interview with Touchpoints at Bloomfield’s Director of Nursing Shanta Griffiths and iCare Health Network’s Director of Transitional Care Sarah Landi. Tune in to Fox61 on Valentine’s Day or check back here for the full interview.
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Honoring Dr. Martin Luther King, Jr.

January 21, 2019

There are so many deep and meaningful quotes attributed to Dr. Martin Luther King, Jr. “The time is always right to do what is right” and “Life’s most persistent and urgent question is, ‘what are you doing for others’” resonate strongly for those in healthcare and in daily service to others.
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Touchpoints at Farmington Makes Technology and Social Media Training Available to Residents

January 18, 2019

In partnership with social media and web consultants New Industria, Touchpoints at Farmington provided technology and social media training to residents. Knowing that with the holidays comes new gadgets, Touchpoints offered an hour long training session for a handful of residents on use of their tablets and devices, how to stay connected via social media and email, and other topics meant to increase their accessibility and communication with loved ones and their communities.
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Transitional Care Programs and Services

Touchpoints at Bloomfield

Touchpoints at Farmington

Touchpoints at Manchester

Touchpoints at Chestnut