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