Hospital to Home – Care Transitions Program

This is a program to enable a seamless transition from hospital to home, enhance the patient experience, coordinate patient-centered care to reduce Hospital Re-admissions. We work collaboratively with providers and are committed to improving transitions from hospital to home.

Heart Failure Program

This program increases the Patient’s knowledge regarding heart failure, thus improving their quality of life and reducing Rehospitalizations. Teaching on causes of Heart Failure, Signs and Symptoms associated with Heart Failure, Treatment guidelines, Dietary education, and Medication management.

Chronic Disease & Self-Management Program

This is an effective self-management education program for people with chronic health problems. The program specifically addresses heart disease, diabetes, lung diseases and also teaches skills useful for managing a variety of chronic diseases.  The program will assist patients with declining chronic conditions that require symptom management. Our professional clinical nursing team will meet your skilled needs and manage a care plan with your doctor that may include: Therapy, Medical Social Work, Care Specialists and Home Health Aide Services. Care Coordination and management includes a nurse follow up call to you after discharge.

Joint Replacement Program

As prescribed by your physicians post-surgical care will includes the therapy goal of restoring functional strength and to provide a home exercise program that improves mobility to enhance optimal recovery. The Clinical Staff works with the patient regarding any medical concerns to proactively identify and resolve any potential risk factors.