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Services A La Carte

In-home Visit by an Registered Nurse

(up to 90 min - most visits are approximately 60 - 90 min)

  • Complete nursing assessment including vital signs, heart, lung, skin, and disease-specific assessments
  • Obtain records from all physicians involved in care and ensure accurate and matching information is present
  • Complete medication reconciliation (see below for details)
  • Communicate any important information to physicians
  • Fill pill planners and create reminder system
  • Educate on disease processes and medications
  • Communicate with designated family member
  • Provide skilled nursing services including wound care, central line care and infusion, catheter care, etc

Care Coordination and Navigation

(up to 4 hours per month, then addtional charges apply)

  • Obtain records from all physicians involved in care and ensure accurate and matching information is present
  • Complete medication reconciliation
  • Coordinate between physicians
  • Set up medical appointments needed
  • Asses for medical and non-medical needs and connect client to resource (PT, OT, Meals on Wheels, housekeeping, in-home hair stylist, down-sizing assistance etc.)
  • Provide education on disease processes and medications
  • Advocate for clients to ensure they are getting the care they need
  • Provide updates to designated family member

One-time Medication Reconciliation

  • Obtain medical records from all physicians, hospitals, and facilities and ensure all information is accurate
  • Review all medication lists and ensure each physician has the same information
  • Review all medications by looking for
    ○ Duplicate therapies
    ○ Negative interactions between medications
    ○ Unnecessary medications
    ○ High risk medications for those over 65 years of age
  • Asses client for effectiveness of medications and side effects
  • Communicate any findings with ordering physician and implement any new orders given
  • Update all other physicians on any new orders

Transition from Hospital to Home

  • Meet client at the hospital
  • Recieve report from discharging nurses and case manager
  • Transport or meet client at home (depending on if ambulance transport is needed)
  • Assist client in getting settled and comfortable at home
  • Conduct a complete medication reconciliation and ensure client understands the new schedule
  • Preform any skilled needs the day of discharge (wound care, IV care, etc)
  • Pick up and deliver any prescriptions
  • Communicate important information to other physicians and family
  • Check-in phone calls the during the next week to ensure complete understanding of discharge instructions and monitor progress


End of Life Care

  • Work in conjunction with hospice
  • Ensure client is comfortable
  • Provide extra support during end of life
  • Administer medications when needed
  • Provide information on what to expect and provide compassionate support
  • Sit with client so family can step away for dinner or a walk

Transport and Attend Medical Appointments

(up to 3 hours, then addtional charges apply)

  • Pick up and drop off at home, ensuring client is safely inside and settled in after drop off
  • Attend appointments and assist with providing important information to the physician that the client may have forgotten
  • Ensure client understands what the physician says
  • Set up any follow-up appointments
  • Communicate any significant changes regarding treatment, medication, diagnoses, or disease progression, to all physicians involved in care to ensure continuity of care

Transport and Attend Medical Procedeures

up to 3 hours (additional payment for each additional hour)

  • Educate on any preparation needed, ensuring the client understands
  • Pick up the client at home
  • Act as an advocate and representative for a client
  • Remain present or nearby during the procedure
  • Educate and assist the client with post-procedure instructions given
  • Take the client home and remain with the client until they can safely be alone
  • Make any follow-up appointments necessary
  • Update a designated family member
  • Update other physicians on any findings

Check-in Phone Calls

  • Provide check-in phone calls per client needs and preferences
  • Weekly or twice weekly phone calls to check on the client’s health status and well-being
  • Every other day call for conversation and companionship
  • Daily medication reminder phone calls
  • Create an emergency plan with the client to determine the next steps if they cannot be reached. Examples:
    ○ Call back 3 times, if no answer, call the first emergency contact. If contact is also unable to reach the client, call the police for a safety check
    ○ Call back 2 times, if no answer, call the police for a safety check