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.
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, 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
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On September 12, 2024, iCare Health Network welcomed its newest location to the network, part of the MissionCare Health service line. The center was formerly known as Bennington Health and Rehab and was relaunched as of 12:01AM as MissionCare at Bennington. An informal ribbon cutting ceremony for residents and staff was held with a more formal event to be held in the coming weeks. A 91 bed center in southwestern Vermont, MissionCare at Bennington will provide similar services to sister facili… -
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A believer in God and hard work, Wright remembers being a young CPA watching from his window as an office building was built from the ground up. The business inside — the Brian Center Corp. — eventually hired him as a financial analyst for its skilled nursing operations. Wright found his calling and realized something else. “There are people behind the numbers,” he says. Wright, now president and CEO of Connecticut-based iCare Health Network, grew up in Vale, NC. The rural, unincorpo… -
On August 27, 2024 the team at Touchpoints at Chestnut put on a carnival and celebration of the iCare Health Network 25th Anniversary for staff and residents. Touchpoints at Chestnut was the first iCare center to hold their celebration with many still to come. Each celebration will feature a cameo appearance from Prince, to help us in partying like its 1999, iCare’s founding year. The carnival included cotton candy and other sweet treats, giveaway items, carnival food and music. Great … -
Westside Care Center Celebrates Two Retirements
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On August 29, 2024 the team at Westside Care Center celebrated with staff the retirement of two members of the team. Lorna Christie retired after eight years of service as a CNA and Lynne Ambrose retired after 38 years as a CNA, both at Westside. A celebration was held at the care center with well wishes and many thanks. -
Jess DeRing Presents on Specialized Long Term Care at Home and Community Based Services Conference
August 26, 2024
On August 20, 2024, Jess DeRing, Director of Operations for MissionCare Health, presented “Creating Specialized Long-Term Care Facility for Justice-Involved & Difficult to Place Individuals at the 2024 Home and Community-Based Services Conference in Baltimore, MD. Jess’ presentation included details and background on MissionCare Health including the origins of 60 West, MissionCare at Holyoke and the upcoming MissionCare at Bennington in Vermont. -
Fresh River Healthcare's Justine Attenello Shares Thoughts on 36 Years of Service to Residents and Families
August 8, 2024
As part of celebrating iCare Health Network’s 25th Anniversary, we are highlighting some of our many talented and committed long-tenured employees. Here, Fresh River’s Justine Attenello reflects on her years of service, how she came to work at Fresh River Healthcare in 1988 and some of her favorite moments working in the care center. -
On July 26, 2024, iCare Health Network premiered its newest commercial, highlighting and honoring some of iCare’s longest tenured employees and its specialized clinical programs. The commercial debuted on multiple platforms during the 2024 Summer Olympics on NBC in Paris.
