Transitional Care Management

Standing out by reaching out

PHS is an employer of uniquely skilled and talented Providers (primarily Nurse Practitioners) practicing in post-acute settings across America. PHS provides an innovative solution to the increasing medical needs and challenges in the post-acute care settings we are privileged to serve, such as Nursing and Skilled Nursing Facilities, In-Patient Rehabilitation Centers, Assisted Living Facilities and in patient’s homes.

Each and every day, PHS Nurse Practitioners make a difference in the lives of countless people, and not just the residents and patients in their care.

We share a common goal with the Facilities we work with of finding better and more cost-efficient models of delivering quality care to seniors.

Together, we achieve uncommon results.

Doctor Talking With Her Patient

What can I expect the Nurse Practitioner to do for me at home?

• Conduct a brief Health History

• Conduct a Physical Exam

• Conduct a Home Environmental Safety Assessment

• Conduct a Medication Reconciliation

• Review Medications and assess medication needs

• Assess laboratory needs

• Communicate with your Primary Care Physician

How is this different than Home Health?

The PHS Nurse Practitioner performing this visit is an experienced clinician. He/she can write prescriptions, prescription refills, and/or lab orders if necessary. Home Health is an ongoing service provided by a home health agency in which nurses (LPNs and RNs), and sometimes therapists (PTs, OTs, STs) and social workers come to your home intermittently over a period of weeks to provide nursing and therapy and educational instruction regarding your condition(s). The Nurse Practitioner visit supplements the home health service, but is not affiliated with the home health service.

Why do I need a Home Visit conducted by a PHS Nurse Practitioner?

The Nurse Practitioner taking care of you in the Skilled Nursing Facility was a PHS Nurse Practitioner. He/she works in collaboration with the physician who also cared for you in the Skilled Nursing Facility. A home visit by a PHS Nurse Practitioner will enable your transition to a stable home setting to go more smoothly. Your PHS Nurse Practitioner will have direct access to the records of the Nurse Practitioner from your stay in the Skilled Nursing Facility. The PHS Nurse Practitioner visiting you at home can also discuss your current status and situation with the Nurse Practitioner in the skilled setting and together, they can identify clinical concerns or changes in your condition that may have occurred since your return home. This continuity of care greatly enhances the safe transition back to your home, which is everyone’s goal.

What is a Transitional Care Home Visit?

The transition from a Hospital or Skilled Nursing Facility to your home can be stressful and sometimes frightening. A transitional care home visit is a clinical visit conducted within two weeks of a patient being discharged directly to their home from a Hospital or Skilled Nursing Facility.

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