Hospital/Rehab to Home Program

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Silver Smooth Transitions Package

Silver Tree Home Care’s Silver Smooth Transition Package helps families and patients prepare for the increased needs of a loved one at the time of discharge from a hospital stay, a nursing home rehab facility, or an outpatient facility. Silver Tree Home Care is committed to reducing the risk of re-hospitalization by offering reliable in-home support of discharge plans and continuous follow-up throughout the recovery process.

Most patients are excited to return home but sometimes there are unexpected challenges that can occur after a patient is discharged. If proper planning and care are not established at the time of discharge, the patient may have to be readmitted to the hospital within a short time after their discharge. According to the Medicare Payment Advisory Commission (MedPAC), close to 20% of patients are readmitted to the hospital within 30 days of discharge. Most of the re-admissions are avoidable. Through an understanding of how to avoid readmissions, patients can return home safely, improve their quality of care, and reduce their overall healthcare spending.
Some of the reasons for hospital readmissions are often due to poor communication during the discharge process, medication errors, falls, not making follow-up doctor appointments, not obtaining physical assistance, and not arranging in-home support.

The highest risk of readmission, as noted by MedPAC, are patients with pneumonia, heart failure, COPD, psychoses, intestinal problems, dementia, and malnutrition. In addition, patients who live alone and do not receive home care services are twice as likely to be readmitted.

Here are some questions to ask in order to ensure a safe return home for you or someone you love:

  1. When you leave the hospital, will you go to your own home? A family member’s home? A rehab facility?
  2. Do you understand your medication instructions? Do you need therapy or treatments and who will be providing treatments?
  3. Will you need transportation and or assistance getting to your follow-up doctor appointments? To the pharmacy?
  4. Will you need help with medication reminders? Bathing? Meal Preparation? Light Housekeeping? Who will assist you? Will a family member, a friend, or a home health aide assist?
  5. How long do you anticipate needing help?

Silver Tree guarantees a smooth transition during the discharge process by coordinating services with any other agencies involved in the discharge process.

Our Silver Smooth Transition’s package includes:

  • Four hours of homemaker and or personal care services.
  • Transportation to or from the facility
  • Assistance with discharge orders
  • Prescription pick up
  • Safety walk throughout the residence to prevent possible falls
  • Medication reminders
  • Meal preparation with special attention to dietary instructions and needs
  • Assistance with bedtime in the evening or naps.
  • Light housekeeping chores
  • Personal care including bathing, hygiene assistance, dressing
  • Review of doctor notes and transitional care with family
  • This one time service is offered at a rate of $79.00
  • Additional care over the 4 hours is offered at an hourly rate.
  • Caregivers are compassionate, carefully assessed and tested, background checked, drug tested, bonded and insured.
  • Silver Tree is a Kentucky state licensed home care agency.

Please call 502-240-6464 for more information on how we can safely transition your loved one home and for a complimentary discharge planning checklist.

For more information Hospital & Rehab to Home Program, please call us at 502.240.6464.