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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

  • Today, 60 West in Rocky Hill was one of the long term and post-acute care providers recognized with a 2020 Silver - Achievement in Quality Award by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL). Recipients of this prestigious award have demonstrated a commitment to a rigorous journey of continuous improvement in the quality of care provided to residents.  “We have been referring to this at 60 West as our Silver Lining to 2020. We are honored…
  • October 15th is Global Handwashing Day – a day and a practice that has taken on much greater significance during the ongoing COVID pandemic.  The first Global Handwashing Day was held in 2008, when over 120 million children around the world washed their hands with soap in more than 70 countries. Since 2008, community and national leaders have used GHD to spread the word about handwashing, build sinks and tippy taps and demonstrate the simplicity and value of clean hands. Organized by: The…
  • On October 1, 2020 iCare Health Network President and CEO Chris Wright announced in a memo to employees that Allison Breault had joined the company as its new Chief Clinical Officer.   “It is my pleasure to announce that Allison has accepted the new Chief Clinical Officer position for iCare Health Network. She brings to iCare a wealth of experience in executive clinical management. In addition to Bachelor of Science in Nursing, she has a Master of Science in Nursing Administration and…
  • Today the Touchpoints at Farmington team, including the Heart Failure Program’s Transitional Care Nurse and the Touchpoints Therapy team, among others, received a glowing testimonial in the form of a Yelp Review. “  I had a lot of positive experiences. The staff at the facility was working with me very closely. I know I could not have done it by myself. I am happy to finally be returning home after a long stay however I greatly appreciate all the help and support provided to me by t…
  • As of September 28, 2020, Governor Lamont and the Department of Public Health lifted the restriction on indoor visitation in nursing homes in Connecticut. As of this week, all iCare Health Network care centers will be allowing and supporting indoor visits in addition to continuation of outdoor visits, weather permitting. Each care center will have some specific guidelines depending on the center’s layout, staffing and other needs. Below are a list of guidelines and infection control measures. …
  • I have such phenomenal appreciation for all of the staff. I don’t believe you receive enough gratitude and recognition of just how much you are greatly valued and loved for your diligent hard work at Touchpoints. You are the scaffold that keeps this place afloat. And though not everyone is able to express their support to you, please know it is on the minds of all the residents. 
  • 60 West started off the week by recognizing and thanking the housekeeping and laundry staff that are a critical part of their environmental services team and daily operation.  As with much of iCare’s recognition it came in the form of treats! September 13-29 is National Healthcare Environmental Services Week and their service means even more in 2020 as the COVID pandemic continues and environmental services teams are on the front lines everyday. A safe, hygienic, orderly, compliant and c…
  • On September 8, 2020 the team at Optum/United Healthcare treated the residents and staff of Touchpoints at Bloomfield to a tasty Summer treat of tropical shaved ice from the Kona Ice Truck.   Staff and residents had the opportunity to enjoy some sun and fresh air while picking out a shaved ice flavor. Some staff were seen dancing down the sidewalk! Optum/United has sent treats, snacks, recognition, thanks and relief to many of iCare’s care centers and we appreciate their thoughts and con…