Whether your transition is from the acute setting to home or from wanting cure focused care to care focused on symptom management and quality of life-We meet you where you are on the bridge to recovery , healing, or end of life care.  We provide transitional, chronic and palliative care management using Nurse Practitioner house call visits to help prevent hospital admissions, coordinate your care, and treat symptoms, help manage chronic diseases,  and address acute illness.

• Post Acute Transitional care (30-60 days of weekly NP visits after an acute admission, 

• Chronic care management/house calls, Palliative Care-routine NP visits chronically with a focus on disease management, prevention of hospital admissions, communications with other providers, educations, symptom management.

• Medication reconciliation to prevent medication errors

• Order Mobile X-Rays, Labs, or other Diagnostic Tests as needed

• Patient phone contact by within 2 business days of discharge

• NP visits at their residence within 7 business days of discharge from an acute facility then every 1-2 weeks until stable

• Refill and adjustment of prescriptions

• Risk assessment at visits to determine risk of readmission and frequency of follow up visits indicated

• Coordination of care and communication with home health, PCP, and specialists

• Thorough review of hospital records with follow up on labs, diagnostics, or orders. Records are left with the patient for their PCP

• Education of the patient/family on their diagnoses, disease processes, medications, follow up appointments, and discharge instructions

• Assistance with coordinating readmission to the acute care/rehab system if indicated

• Referral of patients to our partner facilities as needed

• Nurse Practitioner on call triage services during 30 days post discharge period after office hours and weekend

• ​Recommendations to other providers involved in the patient’s care