Transitions to home

“To ensure a smooth and steady recovery, we bring in a geriatric nurse to help. This professional will work with the discharge planner and implement proven strategies that studies show reduce the chance of a hospital readmission. We put the research to work for you!
—Brian Gauthier, gerontologist, owner of A Family Member HomeCare

Did you know that up to 20 percent of patients who get discharged from the hospital are readmitted within thirty days?

Often, they have been sent home too soon with inadequate support. This is a nationwide problem, but it can be fixed. We apply the findings of the latest research studies to ensure that your loved one has the support they need to avoid a preventable readmission.

Need help with discharge planning and the transition home?
Give us a call at 1-866-Brian-XO (866-274-2696).

We offer state-of-the-art care based on research findings that promote a smooth recovery:

Nurse supervision

A geriatric nurse is assigned to your family before the hospital discharge (or discharge from a rehab facility). We carefully go over the discharge planning and take note of all the things that need to be set up at home. Is a hospital bed required? A bedside commode? A Hoyer lift? We will coordinate with discharge planning to smooth the transition back to the home setting.

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Medication reconciliation

The new prescriptions will be integrated into the medication schedule. We do a complete medication reconciliation when your loved one arrives home. If there is any question—and often there is—our geriatric nurse will make the necessary phone calls to be sure medications don’t go missing. Then pillboxes or automatic pill dispensers will be filled so you can rest assured your loved one is taking everything they are supposed to be taking when they are supposed to be taking it.

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Monitoring for problems

We have caregivers who are experienced at recognizing signs of a developing problem and can spot the red flags of a recovery going south. Did your loved one suddenly get a spike in blood pressure? A rise in weight? Is it difficult to sleep lying down due to persistent coughing at night? Our caregivers can call the geriatric nurse whenever they notice a worrying symptom. Typically, a call to the doctor or standing orders can be implemented and spare you a crisis run back to the hospital.

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Follow-up doctor's appointment

The research shows that an appointment after discharge with the appropriate specialist is paramount. We advocate for your loved one and make sure an appointment is set for seven to ten days after discharge.

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Medically complex situations

If the person you care for is considered a “high-acuity patient,” meaning they have many conditions and challenges, you’ve come to the right place. We specialize in complex situations. We can arrange for 24-hour home care, either on a live-in or hourly shift basis. Plus, a geriatric nurse is on call 24/7 to provide medical assistance or insight when needed.

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Multiple transitions

And if your loved one does need to go back—some conditions simply require more time with intensive medical supervision—our geriatric nurse is there to ease the transport back to the hospital, ensure the hospital team understands the latest developments, and has a complete medication list. When it’s time to go home again, we are there to smooth the transition.

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