Leigh Ann talks about our TCM (Transitional Care Management) Program

For patients who have been hospitalized or rehabilitating for many days or weeks, transitioning from a hospital or skilled nursing facility back home can be stressful and sometimes difficult. A transitional care home visit by a Nurse Practitioner (NP) can help smooth the way and keep patients on the track to getting better. This type of clinical home visit is made within two weeks of discharge.
Key Points:
Importance of Home Visits by Nurse Practitioners:
Ensures continuity of care.
Facilitates smoother transition to a home setting.
NP has access to medical records from the facility you were discharged from.
Benefits of Nurse Practitioner Visits:
Concise discussion about your current status and situation with the provider team.
Identifies clinical concerns or changes in your condition since returning home.
Enhances safe transition back to home.
Services Provided by Nurse Practitioners:
Experienced clinicians.
Can write prescriptions, refills, and/or lab orders.
Work alongside Home Health services to supplement care.
Difference Between NP Visits and Home Health Services:
Home Health is provided by a separate certified agency.
Home Health involves RNs, LPNs, therapists (PT, OT, ST), and social workers.
Home Health provides nursing therapy and educational instruction intermittently over weeks.
Palliative Community Resource Nurse Practitioners are not affiliated with Home Health services.
Cost Considerations:
Like a physician or NP office visit, you may be responsible for a copay of approximately $35, depending on your insurance.
Ensure a smooth and safe transition back to your home with the help of a Nurse Practitioner’s transitional care home visit.