Care Transitions Management

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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 these patient’s transitions from the in-patient setting to the community. Pyramid Home Health Services Care Transitions Management provides 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’ 24x7 nurse line, their physician(s) contact information and follow-up visit dates, and a list of the addresses, contact numbers 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 patient’s 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- 24X7 Nurse Line makes available a Pyramid Home Health Services Clinician to provide telephone based response to patient health questions and concerns and to triage alternative care options to the ER after hours. Response is stepwise and ranges from the least invasive- advice and follow-up telephone monitoring to scheduling of a physician office visit or referral and arranging of transportation to, if required, the nearest open emergent care clinic. All documentation of interactions will be provided to the patient’s following Physician(s), discharging hospital and health plan within 24- hours or sooner where appropriate.

5- Weekly or more frequent if necessary 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.


Pyramid Home Health Services provides comprehensive care transitions management under contract to Health Plans, Hospitals, and ACO operating in Missouri. Pyramid Home Health Services also provides this service directly for individuals and their families wanting assistance with their return home from the Hospital or Nursing Home. 

Care Transitions Management can be purchased on a flat fee basis; which covers all services listed above and for the individual’s entire 30-day post discharge period. Health Plans, Hospitals and ACO interested in PMPM and other “At Risk” pricing solutions may contact Cale Bradford, COO at 800-457-1975 or via email at This email address is being protected from spambots. You need JavaScript enabled to view it..

 

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