Hospital/Re-Hab to Home

Touched by Angels Hospital/Re-Hab to Home Program

Let Touched by Angels help your family with this challenging transition time. Life is stressful enough when you or your loved one has been ill, hospitalized or re-covering. Our professional care transition team will provide seamless, compassionate, expert assistance in the crucial days, weeks or months following a hospitalization or re-habilitation.

Our goal is to ease the challenges of this difficult transition with our skilled team of hospital to homecare angels. We specialize in providing safety and comfort, patient and family education and preventing re-hospitalization. We care for your family as if it were our own.

Tell us your story. Our professional care manager and discharge planner will meet you at the facility to help manage and plan all your homecare transition needs with our patient care transition assessment. Our transitional care manager will make a home visit immediately, followed by the arrival of our highly trained expert caregivers. The Care Manager will follow you closely to make sure all your family needs are being met, help prevent overwhelm and speed recovery.

Touched by Angels also offers free weekend in-home assessments for families whose needs transcend the nine-to-five work week.

Transition Services include:

• Initial telephone or in-person consultation and personalized transition care plan, including a mental health and depression assessment.
• Professional care manager will meet you at the hospital or rehab center, and will meet with the facility discharge manager.
• Transportation to home or assisted living if needed.
• First caregiver shift may begin immediately upon request.
• Communication with Medicare or your private insurance provider to obtain forms and provider instructions.
• Complete medication management including pharmacy calls, medication check and side effect education.
• Transitional care nurse available for questions and concerns.

Caring for you or your loved one like a treasured family member – is our specialty!

Once at Home Care Services include:

• Preceding or upon arrival at home, we will tidy or house clean.
• Home safety assessment including recommendations for equipment or home safety modifications.
• Implementation of our certified fall-risk reduction program by highly trained caregivers.
• Daily monitored support for helping the patient and family comply with medication needs and schedule.
• Personal care assistance such as bathing, grooming, dressing, toileting, skin care and transferring – customized to individual patient needs.
• Errands, shopping, prescription pick-up, pet care and all light housekeeping such as: laundry, vacuuming, dishes, dusting, and general kitchen, bedroom and bathroom cleaning.
• Meal preparation in alignment with physician recommendations.
• Ongoing, detailed medication management including reminders and side effect cross-referencing and education.
• Disease and self-care education and prevention along with red flag alerts, identified and customized for patient safety and improved recovery.
• Companionship and emotional support throughout the recovery.
• Communication with physicians and all healthcare providers (physical and occupational therapist, nutritionist, social worker, hospice team and more). This includes rehabilitation and exercise prompts with the goal of multiple physician accountability.
• Making, canceling and follow-up for all healthcare appointments if needed.
• Transportation to doctor appointments, rehabilitation sessions and personal events.
• Identifying patient and family needs for community resources and obtaining them.
• Communication with family members through online “point of care” system.
• Regular updates to designated family or friends, if requested.

The statistics show that many hospital patients are readmitted within thirty days due to outdated discharge planning failures. We have trained our staff to change these statistics and KEEP YOU OR YOUR FAMILY MEMBER AT HOME!

Re-hospitalization Prevention and Recovery Stabilization is our Goal. Every Day in Every Way!