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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

  • iCare Health Network will be holding a week of Job Fairs and Hiring Events across the network on November 1-6, 2021. The Job Fairs have a wide range of locations and times to maximize flexibility. Candidates can present to any location at any time to interview for any open position.  iCare is recruiting for full-time, part-time and per diem positions! Locations include all iCare Health Network care centers across greater Hartford and western Massachusetts and iCare’s home health agency, Tou…
  • On October 12, 2021, as part of the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) Annual Convention and Expo in Washington DC, Administrator Jessica DeRing accepted a Silver - Achievement in Quality Award on behalf 60 West, originally awarded to the care center in 2020.  According to AHCA-NCAL, Silver Award winners have demonstrated effective approaches that help improve performance and health care outcomes. Recipients of this prestigious award have d…
  • iCare Health Network will celebrate National Case Management Week 2021 on October 10-16, 2021. Case Management Week is a time to celebrate case management and transitions of care professionals for the good work they do each and every day. Case managers, usually registered nurses, social workers, physicians or other health professionals, provide collaborative clinical assessment, care coordination, patient education, counseling, case monitoring/clinical pathway management, discharge planning, re…
  • iCare Health Network is a leading provider of long term care to residents with a behavioral health diagnosis in multiple settings and care centers, including in six secure behavioral health units across the network. As such, iCare works towards a stigma-free environment for behavioral health care and supportive services and recognizes the importance of awareness of mental illness. The National Alliance on Mental Illness (NAMI) has designated October 3-9, 2021 as Mental Illness Awareness Week. 
  • On September 30, 2021 the team at Fresh River Healthcare celebrated Susie Taylor and bid farewell as she retires. Susie spent 17 years with iCare, having worked in scheduling, payroll, human resources and reception, including stints at 60 West and Fresh River. Employee longevity is a great testament to a quality workplace and a commitment to the teamwork needed to serve every day. iCare wishes to thank Susie for her many years of dedication to the residents we serve and to the staff who worke…
  • East Windsor First Selectman Jason Bowsza visited Fresh River Healthcare on September 28th. The visit and tour was part of Mr. Bowsza’s outreach to businesses across East Windsor. Administrator Elise Cecil provided information on the care center which specializes in memory care, movement disorders such as Parkinson’s and Huntington’s disease, behavioral health and long term care. Mr. Bowsza had the opportunity to meet and speak with residents and members of the staff.  Thank you …
  • iCare Health Network will be holding a CNA Job Fair and Hiring Event on October 6, 2021.  iCare Health Network is recruiting for full-time, part-time and per diem positions! Locations include all iCare Health Network care centers across greater Hartford and western Massachusetts and iCare’s home health agency, Touchpoints at Home. See all open positions at WWW.ICARE.CAREERS. 
  • iCare Health Network will be holding a large RN Job Fair and Hiring Event on September 22, 2021.  iCare Health Network is recruiting for full-time, part-time and per diem positions! Locations include our care centers and affiliated home health agency, Touchpoints at Home. See all open positions at WWW.ICARE.CAREERS. Interview for open RN positions such Nursing Supervisor, Unit Manager, Infection Control, Professional Development, MDS, ADNS, DNS and Other Leadership Roles. Also hiring for CN…