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

• 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