Level I - Going Home Transitions

Our Going Home Transitions program focuses on the little details that make for a smooth transition from a hospital or skilled nursing facility to the comforts of home. It all begins with a simple call to Fedelta Home Care where we will pick you up, take you home and manage everything else in between.

• Discharge Communications
• Transportation to Groceries, Pharmacy, Home
• Personal Care, Meal Preparation, Light Housekeeping
• Bill Pay Assistance, Mail Retrieval
• Telephone Calls to Family & Friends
• Complimentary 24 Hour Check-In Call
• Complimentary Lifeline Installation

Level II – Nurse Transitions

According to acting Centers for Medicare & Medicaid Services agency "data show that nearly one in five patients who leave the hospital today will be readmitted within the next month and that more than three-quarters of these readmissions are potentially preventable." Our Nurse Transitions program provides coaching to patients prior to, and shortly after being discharged from the hospital or a skilled nursing facility. The primary role of the Nurse is to empower the patient and/or caregiver to take a more active role during healthcare transitions, and to develop lasting self-management skills. The Nurse supports patients on a weekly basis that includes a nursing assessment, development of health goals/objectives, home visits, monitoring phone calls and caregiver visits.

Nurse Assessment – Pre-Hospital Discharge
Discharge Preparation/Checklist Medication Review/Management Healthcare Practitioners Communications
Nurse Development of Client Self-Management Goals
Review & Educate on Pre/Post Hospital Medications Introduce Self-Management Skills//Red Flag Identification Facilitate/Assist Medical Care Follow-up
One (1) Nurse Home Visit
Five (5) Nurse Home Monitoring Calls

Nurse Evaluation of Patient Goals & Objectives Five (5) Nurse Monitoring Calls Optional Home Health Aide Visits Additional Nurse Visits Additional Nurse Monitoring Calls Family Caregiver Education/Support Complimentary Lifeline Installation	Nurse Evaluation of Patient Goals & Objectives Five (5) Nurse Monitoring Calls Optional Home Health Aide Visits Additional Nurse Visits Additional Nurse Monitoring Calls Family Caregiver Education/Support Complimentary Lifeline Installation	Nurse Evaluation of Patient Goals & Objectives Five (5) Nurse Monitoring Calls Optional Home Health Aide Visits Additional Nurse Visits Additional Nurse Monitoring Calls Family Caregiver Education/Support Complimentary Lifeline Installation

Level III - Comprehensive Transitions

The Fedelta Comprehensive Transitions program is outlined as follows to increase patient safety, provide safe transitions away from acute care environments, maintain compliance that are congruent with discharge plans and improve client satisfaction scores.

• Comprehensive Nursing Assessment, Diagnosis Evaluation & Care Plan
• Discharge Planner Communications
• Health Review, Baseline Condition & Goals Setting
• Medication Review
• Safety Assessments
• Support System & Physician Communications
• Transportation to Medical Office Visits
• Caregiver Selection & Oversight
• Resource & Services Facilitation
• Home Monitoring & Reporting