Care Transitions by Pyramid Home Health Services

Pyramid Home Health Services assists many Missourians recently discharged from an in-patient hospital stay to rehabilitate at home through the services of its home health division. These services provide individuals with the skilled nursing, therapy, social service and dietary assistance required to recover in the comfort of their own home. Beginning in 2014, Pyramid Home Health Services will begin providing comprehensive care transitions management under contract to health plans and hospitals operating in Missouri.
Many individuals are discharged to home without a specific need for traditional home health services but who are still at risk for complications that may lead to unnecessary ER usage or a re-hospitalization within 30-days of discharge. The key to avoiding this undesirable outcome lays in successfully managing those patients transition from the in-patient setting to the community. Pyramid Home Health Services Care Transitions is a 30-day program specifically developed to avoid ER usage and hospital readmission during that period. Specifically the program:
1- Makes in-person/ in-facility contact with patients at high risk for re-hospitalization prior to their discharge from the hospital. Pyramid Home Health Services staff develops a rapport with the patient and ensures they are knowledgeable of their condition, medical record, medications and, generally, their own responsibilities relating to a successful recuperation at home prior to their leaving the hospital. All patients receive a “Transitions Packet” containing vital information regarding their condition, warning signs and symptoms, discharge medications and instructions, the contact number for Pyramid Home Health Services’ 24×7 nurse line, their physician(s) contact information and follow-up visit dates, and list of the addresses and hours of operation of emergent care clinics nearest their home.
2- Conducts pre-discharge assessment of the safety and accessibility of the patient’s home and provides a written report to the patient’s following physician(s), the discharging hospital, and their health plan covering any identified safety hazards, barriers to self- care or family assisted care, and required home modifications or DME that may be necessary for a successful transition to home. Additionally, if necessary, Pyramid Home Health Services will coordinate orders and referrals for ancillary services, supplies and pharmacy and ensure any required services, supplies or medications are in the patient’s home upon their return.
3- Delivers a home visit within 48- hours of discharge, or sooner where required, to evaluate the return to the home process, the patients satisfaction with the same, address health questions and concerns, check vitals, and review medications and the patient’s knowledge thereof regarding regimen/ dosage(s)/ side effects. Where beneficial Pyramid Home Health Services provides tele-health based MTM (Medication Therapy Management) with a MTM certified pharmacist. Additionally, Pyramid Home Health Services staff reviews and updates the transitions packet, schedules necessary follow-up physician visits and/or ancillary care provider visits, arranges necessary transportation thereto and again reviews with the patient relevant condition warning signs/ symptoms. A written report of this visit is provided to the patient’s following physician(s), the discharging hospital and the patient’s health plan.
4- Within 48-hours of the initial home visit and no less than weekly thereafter Pyramid Home Health Services conducts check-up calls with the patient at pre-arranged times to review their stability at home and their satisfaction with the home transition process. Included in these calls is reminder of and verification of the patient’s making their required physician appointments. If necessary, Pyramid Home Health Services will conduct additional home visits should its calls to the patient or in-bound calls from the patient indicate a potentially worsening condition. Written report of these calls/ visits will be made available to the patient’s following physician(s), discharging hospital and health plan.
If you are a Missouri Hospital or Health Plan and would like to discuss contracting with Pyramid Home Health Services to manage the Care Transitions process for your patients and beneficiaries visit us at or call us at 888-880-6565.

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