Thorough nursing assessment including vital signs, cardiac and respiratory evaluations, skin condition, and specific disease assessments.
Compilation and verification of medical records from all treating physicians for consistency and accuracy.
Comprehensive medication review and reconciliation.
Direct communication of critical information with treating physicians.
Organization of medications using pill planners and establishing a reminder system.
Instruction on disease management and medication usage.
Regular updates and communication with a designated family member.
Provision of specialized nursing care, such as wound management, central line maintenance, infusion therapy, catheter care, and more.
Comprehensive Care Coordination and Navigation
Acquisition and verification of medical records from all healthcare providers.
Medication reconciliation and review.
Coordination and scheduling of medical appointments.
Assessment of both medical and non-medical needs, linking clients to resources like physical therapy, occupational therapy, meal services, housekeeping, personal grooming assistance, and downsizing aid.
Education on disease processes and medications.
Advocacy for clients to ensure optimal care.
Regular updates to a designated family member on the client’s condition and care.
Transport and Support for Medical Appointments and Procedures
Accompanying clients to appointments, aiding in communication with healthcare professionals.
Ensuring client comprehension of physician’s instructions and advice.
Arrangement of follow-up appointments.
Reporting any significant changes in treatment, medication, diagnosis, or disease progression to all involved physicians for cohesive care continuity.
Pre-procedure guidance and preparation education..
Acting as a client advocate and liaison during the procedure.
Staying close during the procedure and assisting with post-procedure care instructions.
Safe return home and support until the client is comfortably independent.
Scheduling necessary follow-up appointments.
Updating family members and other physicians about procedural outcomes.
Medication Reconciliation
Collection and verification of medical records from all healthcare facilities and physicians.
Cross-referencing and consolidating medication lists across all physicians.
Detailed medication review for:
Redundancies in treatment.
Potential drug interactions.
Unnecessary medications.
High-risk medications for clients over 65.
Assessment of medication effectiveness and side effects.
Reporting findings to prescribing physicians and implementing any new prescriptions.
Updating all physicians about new medication orders.
Seamless Hospital to Home Transition
Meeting the client at the hospital for discharge.
Receiving updates from hospital nurses and case managers.
Settling the client at home comfortably.
Executing a thorough medication reconciliation and educating the client on new regimens.
Providing required skilled care on the day of discharge, such as wound or IV care.
Arranging and delivering any new prescriptions.
Coordinating with physicians and family members about care updates.
Conducting follow-up phone calls to monitor progress and understanding of discharge instructions.
End-of-Life Care Support
Meeting the client at the hospital for discharge.
Receiving updates from hospital nurses and case managers.
Settling the client at home comfortably.
Executing a thorough medication reconciliation and educating the client on new regimens.
Providing required skilled care on the day of discharge, such as wound or IV care.
Arranging and delivering any new prescriptions.
Coordinating with physicians and family members about care updates.
Conducting follow-up phone calls to monitor progress and understanding of discharge instructions.
