Transitions-
Placements and Hospital Discharges
Our staff includes a gerontologist, a registered nurse, a registered nurse practitioner, a registered dietician, and an activities specialist.
We have experience across the continuum of care, from home to hospital, nursing homes, assisted living, or memory care. Discharge planning is our forte.
We specialize in high-acuity (medically complex) situations.
Physicians and attorneys turn to our concierge service to make recommendations tailored very specifically to the needs and abilities of their clients. They choose us because we take time to make sure there is a good fit between the client, the family, and the recommended care providers. We focus our attention on a successful and smooth transition. Nobody wants to have to move a second time!
.jpg)
Clients receive a comprehensive assessment of the following:
● Cognitive abilities
● Functional abilities (standing, walking, taking care of themselves independently)
● Medical conditions (medication regimen and need for physical therapy, speech therapy, occupational therapy)
● Driving
● Social isolation
● Personal values and preferences, along with goals of care
We also look at the needs and resources of the family
● Who lives closest?
● Who is able to do what (and for how long)?
● What are the available financial resources?
● What are the family's emotional dynamics?
Following a hospital discharge
Up to 20 percent of patients who leave the hospital end up being readmitted within thirty days. Healthcare professionals and physicians refer their North Shore patients to us upon discharge because they know our hands-on support improves the chances of a smooth and steady recovery.
Recommendations
If aging in place is not an option, we carefully consider the local assisted living, rest home, and nursing home providers, drawing on our more than 75 years of combined experience in long-term care on the North Shore, on Cape Ann, and in the Merrimac
Valley. Our recommendations are completely objective and based on what we think will work best for you.
Hospital to rehab
We also know the best nursing homes and best skilled nursing
facilities on the North Shore, on Cape Ann, and in the Merrimack Valley. Our care managers attend care plan meetings and advocate for your loved one to ensure their
needs and preferences remain front and center.
Our support is hands on
We can provide concierge-level service by touring the recommended facilities with you. Once a decision is made, we can guide you through the moving process and will continue on after move-in to ensure your loved one is adjusting well and that care plans are being followed. Need
to leave town or go out of the country on vacation? No problem! We can serve as your relatives advocate if an emergency arises while you are away.
Hospital to rehab to home
We can recommend the best home care and VNA on the North Shore, on Cape Ann, and in the Merrimack Valley. Upon discharge to your home we make sure all equipment an supplies are delivered and set up. We pick up new prescriptions and set up pill boxes or an automatic pill dispenser based on the new medication regimen and will help to coordinate it all.
Aging in place is feasible.
But you must be diligent with the details.
Put our experience to work for you, along with our knowledge of the local resources.
If you are looking for a medical advocate with concierge-level support, contact us to help you with your eldercare transitions:
Fill this out and we will be in touch!