How we care

Week one: settling in

The visits that keep you out of the hospital.

• Start-of-care nursing visit

  A full assessment, a home safety walk-through and a care plan your doctor signs.

  Medicare

• Medication reconciliation

  Every bottle in the house compared to the discharge list, with the differences sorted out.

  Medicare

• Wound and incision care

  Dressing changes and healing checks, with photos sent to your surgeon.

  Medicare

• Fall-risk check

  Rugs, lighting, bathroom grab bars and the path to the bed at night.

  Medicare

Weeks two and three: getting stronger

• Physical therapy

  Walking, balance and stairs, practiced in your own hallway and porch steps.

  Medicare

• Occupational therapy

  Bathing, dressing and kitchen work made safe again, one task at a time.

  Medicare

• Speech therapy

  Swallowing, word-finding and memory work after a stroke.

  Medicare

• Heart and lung teaching

  Daily weights, breathing plans and when to call us before it becomes an ER trip.

  Medicare

• Home health aide visits

  Help with showers and personal care while skilled visits continue.

  Part of plan

Week four and after: on your own

• Diabetes self-management

  Insulin, meters and meals, taught until you can do it without us.

  Medicare

• Medical social work

  Long-term planning, Medicaid questions and community help like Meals on Wheels.

  Part of plan

• Discharge and follow-up call

  A last visit to review the plan, and a phone call two weeks later to check in.

  Included