Transitional Care Nursing

The Hartford HealthCare at Home Transitional Care Nurse provides patients in the community with a unique service. Unlike traditional homecare services, you do not have to be homebound to receive this free service from a Registered Nurse.

A Transitional Care Nurse provides a patient-centered, free visit to people in the community who are not currently receiving certified homecare services. Our goal is to keep people healthy and safe in their home. We provide health education, assist with connecting you to community resources and communicate with your physician, case manager and other members of your health care team.‚Äč

Download Transitional Care RN Referral Form


Q: How can a Transitional Care Nurse help your patients?

A: The Transitional Care Nurse program has resulted in a reduction of re-admissions, hospitalizations and ER visits falling below the national homecare average. We provide free home-visits and telephonic support while connecting them to community resources, referring to certified homecare services, and while identify barriers and empowering patients to take control of their health.

 

  • Complimentary nursing visit
  • No Face to Face required
  • No Homebound requirements
  • No insurance or payment authorizations

Q: What is a Transitional Care Nurse?

A: The Hartford HealthCare at Home Transitional Care Nurse provides patients in the community with a unique service. Unlike traditional homecare services, the patient does not have to be homebound to receive this free service from a Registered Nurse. A Transitional Care Nurse provides a patient-centered, free visit to people in the community who are not currently receiving certified homecare services.
Our goal is to keep people healthy and safe in their home. We provide health education, assist with connecting patients to community resources and communicate with the physician, case manager, and other members of the healthcare team.

Q: Who would benefit from a Transitional Care Nursing Visit?

A: People who:
  • Do not meet homebound criteria for homecare services.
  • Would like education regarding their medication and disease management.
  • Want to learn more about their medications and how to manage their disease.
  • Have complex medical conditions needing disease-specific education.
  • Have had recent falls or difficulty managing their daily activities.
  • Have had recent Emergency Department visits or hospital admissions.
  • Have little, or no family/caregiver support.
  • Are having difficulty managing or understanding their medications.

Q: What happens during a Transitional Care Nursing visit?

A: You can expect:
  • Comprehensive physical assessment
  • Home safety evaluation
  • Chronic disease education (diabetes, COPD, CHF, pneumonia, etc.)
  • Medication review and teaching
  • Depression and anxiety screening
  • Provides a personal health record
  • Assists in connecting patients with homecare services if needed
  • Assesses financial eligibility for other resources
  • Assist with scheduling appointments
  • Connects patients with community resources to assist with financial issues, transportation, Meals on Wheels, Living Will, Power of Attorney, etc.

Q: Who is eligible for a Transitional Care Nurse visit?

A: Anyone who has a primary care physician or specialist involved in their care! All the patient needs is an order from their doctor, nurse practitioner, or physician’s assistant.

Q: What happens after the Transitional Care Nurse visit?

A: If the patient doesn’t meet the criteria for homecare, the Transitional Care Nurse will continue to call for a 30-day period or longer if needed, to ensure the patient is safe and managing their care. We are here to help answer questions and provide support in many ways.

 

Hartford HealthCare at Home