The transition from a hospital to a post-discharge setting like a rehabilitation center or home can be confusing, complicated and overwhelming. We understand the stress patients and families experience when trying to coordinate communication among multiple healthcare providers across several care locations.
CareConnect Transition Nurse
While you spend quality time with your loved one and family our CareConnect Transition nurse (a certified Case Manager) is focused on all the details of the services needed. every patient is different and those with high-risk conditions present additional unique challenges.
We’re successful because our first step is establishing a supportive relationship with you and your family; it all begins with trust.
Our System is comprised of a network of professionals from a wide range of services and settings:
- Acute Care Hospitals
- Skilled Nursing Centers
- Rehabilitation Centers
- Hospice Care
- Home Care
- Memory Care Specialists
- Independent Living Campuses
- Assisted Living Communities
Together we are committed to working toward the best possible outcome, communicating openly and navigating a complex healthcare environment.
Learn more about our CareConnect partners.
The PLACES assessment tool, which is used by our whole system, identifies patients at high risk for re-admission to the hospital. Our goal is to manage the care and resources needed by those most at risk for adverse events.
How CareConnect Works
The Care Transition Nurse is responsible for following at-risk patients during a skilled nursing center stay, through their home health episode and for 30 days beyond the last service.
Care Transition Nurse
- Coaches patient on maintaining health
- Communicates with the primary care physician to ensure follow up appointments after arriving home
- Communicates with patient and/or family at 1-2 week intervals
- Monitors patient progress