When a patient is discharged from an acute setting, such as a hospital, nursing home, treatment facility or rehabilitation facility, they can face new challenges. Often, patients require home health services when they’re housebound due to illness, accident or surgery. Accessible Healthcare, LLC establishes a patient-centric transitional care program. Our program is designed to ensure that the patient receives safe, effective and coordinated care upon transfer or discharge.
Once engaged, our care team coordinator will manage the patient’s discharge or transfer in a timely manner, address the immediate and long term goals and risks, coordinate the immediate care, and ensure that services are positioned to eliminate the need to return to the acute setting.
Our transitional care platform incorporates “Care Team” philosophy with integrated post-acute services and case oversight. These resources include:
• Case Management
• Mobile Physician
• Outpatient Treatment Centers or Clinics
• Patient or Family Member Support
• Personal Care Attendant
• Personal Care Coordinator
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Primary Care Doctor
• Psychological Support
• Social Worker
• Specialist Physicians
Each patient will receive a comprehensive assessment and a treatment plan to ensure the best possible outcome. And, we’ll communicate with you and other care team providers to keep you apprised of the patient’s status as well as identify other potential diagnoses.
Our transitional nurse or home health physician will be available to visit with the patient prior to discharge. After a comprehensive assessment of the patient, resources and challenges, the patient’s post-care is organized with the care team. The patient and family are educated on “What’s Best Next” and services are booked and ready for post-discharge delivery.
An RN or physician consults with the patient 12 to 24 hours before discharge. Based upon medicare standards we will perform an Oasis evaluation , full medication reconciliation , fall risk assessment and a mandatory pos-acute physician visit will be scheduled. During the risk period, patients receive phone calls from the care team as often as needed to ensure program compliance and medication adherence as well as bond with the nursing department.
If a patient is a high risk chronic condition(s)they will be enrolled in our long term care program. Because patients have a strong tendency to fail after hours and on weekends, we’re available 24/7 via phone, video conference and in person.
Once a patient has been successfully transitioned for 30 consecutive days, we’ll perform periodic health checks to head off potential health issues, answer questions and identify new diagnoses. These health checks are performed as often as needed based upon each patient’s unique needs.
Medication issues account for 1/3rd of readmissions. And if not managed properly, will expedite the patient’s decline in health. We perform medication reconciliation upon engagement and communicate the patient’s medications to the pharmacy and physicians.
This ensures that the patient is not taking duplicative therapies or drugs that could induce poor outcomes. We also educate the patient and family regarding the appropriate use and potential side-effects of the medications. For patients with multiple medications and comorbidities, a medication therapy management program may be recommended. This requires a consult with pharmacist and physician. In cases where patient are not managing their medications properly, more advanced systems may be employed, such as medication reminder systems, electronic pillboxes, toxicology screening, and weekly reconciliations.
One fourth of people over the age of 65 have at least one chronic disease and many have two or more. Often, post-acute patients with chronic disease are at high risk for hospital re-admission. Another issue facing patients with chronic illnesses are the undiagnosed diseases they may have as well as early stages of new diseases. Multi-chronic patients are considered complex cases and require specific personalized care programs.
The Accessible team implements specialized care protocols for the management of chronic illnesses. Protocols are available for:
• Heart Failure (HF)
• Chronic Obstructive Pulmonary Disease (COPD)
• Acute Myocardial Infarction (AMI)
• Cancer (CA)
• Coronary Artery Disease (CAD).
Long Term Care
All of our services can also be provided in the patient’s place of residence. Generally, there is no insurance limit on how long a patient can receive services as long as they remain medically necessary and the doctor reorders them every 60 days.
Accessible helps patients cope with the social, psychological, cultural, and medical issues that result from long term illness. This may include facilitating access to additional care, including D.M.E. and follow-up care, explaining how to use health care and other resources, and education on specific disease and treatments. Patients that have a risk requiring extended coordinated care (generally, longer than 30-60 days), will be enrolled in our long term care program.
Palliative Care Program
The primary goal for Palliative Care is to control pain, manage symptoms and side-effects for aggressive treatments and galvanize family support for housebound patients with serious or advanced stages of illness.
In many cases, palliative care is administered before hospice is introduced. The palliative team generally includes patient, physician, social worker, nurse and patient advocate.
Our main goal is to keep the patient in the comfort of their own home or place of residence.
Palliative Care Program
When homebound patients or family members have concerns about the patient’s ability to manage medications, transportation, activities of daily living, eating right, incontinence, housekeeping and personal care, Accessible will recommend utilizing a personal care attendant service.
When home health is ordered but the patient is not eligible for benefits, the patient may opt to pay privately for home health or a personal care assistant. Insurance may cover non-medical services in cases when in home skilled services are not covered.
By bonding patients with primary care, specialty clinics and transportation, a patient can achieve a higher quality of life with a personal care attendant.
Palliative Care Program
Our Care Management system includes:
• Needs Analysis
• Care Coordination
• Benefit Management
• Placement Assistance
• Booking Services
• Vendor and Provider Management
• Patient and Caregiver Relations
• Care Program Enrollment
• Follow Ups
• Customer Care
• Alert Management
Accessible’s care management team uses case management software, electronic medical record integration and a 24/7 responsive care line.