FACT:  Patients face a significant risk of adverse events during the transition from the hospital to the home, therefore continuity of care is most critical during the patient’s transition from the institutional acute care setting to the community or his or her home. Effectively executed care transitions are predictive of positive outcomes. 

Poorly executed care transitions negatively affect patients’ health, well-being, and family resources and can potentially lead to avoidable re-hospitalizations. Experts estimate that 20% of persons hospitalized in the US are re-hospitalized within 30 days of discharge. According to an analysis conducted by the Medicare Payment Advisory Committee, up to 76% of re-hospitalizations in the Medicare population that occur within 30 days of hospital discharge are avoidable. However, many patients lack the support to assist with basic tasks to ensure a successful, safe discharge home.

Ezra Home Care has developed a program to help patients ensure a safe transition home that will keep them out of returning to the hospital. A member of our team will participate in the discharge teaching/instruction process at the Skilled Nursing Facility, Acute Hospital or Surgical Day Center with the patient. We are available to provide incidental transportation, grocery shopping, prescription pickup, medication reminders, light housekeeping, home modification (to assist with fall prevention), laundry and meal preparation for the first 24-48 hours post discharge as well as additional hours as needed.

For those residing in a facility, supportive services are available to supplement the care provided by the facility staff. Adjustments to surroundings and medication modifications can be the source of behavioral issues which may require one-to-one care.

Core Programs Elements:

  • Comprehensive client assessment and participation in discharge planning
  • Development and implementation of a client-centered care plan
  • Assistance with medication management and behavioral management
  • Ongoing communication and collaboration with family members and other care providers
  • Personal care assistance with activities of daily living
  • Appointment escort and incidental transportation

For more information, contact Ezra Home Care at 617-527-9000 or info@ezrahomecare.com