For patients who have medical and/or psychosocial conditions that continue to require a moderate or high level of medical decision making, traditional home health services just aren't enough.
Patients are extremely vulnerable after having an acute episode and the transition from a hospital or skilled nursing facility to home is one of the most overlooked aspects of many post-acute programs. MPAC's Transitional Care Program works in conjunction with traditional home health services to eliminate the potential gap by providing initial and on-going high-level medical care for the patient at home.
Immediately following discharge an MPAC provider essentially serves as an interim primary care provider. In conjunction with home health services, MPAC's Transitional Care Program provides:
- A structured checklist of critical activities designed to empower patients and/or their caregivers before and immediately following a discharge
- On-going in-home face-to-face visits
- Assessment and treatment regimen adherence and medication management
- Training for medication self-management
- Education about symptoms which indicate a medical condition is worsening and how to respond
- A coordinated hand-off to a community primary care physician following the 30 day discharge period
- Assistance establishing or re-establishing referrals and arranging needed community services
- Assistance with scheduling any required follow-up visits with community providers and services