How we care

Days 1–7 · Settling in

The visits that keep you out of the hospital.

• Start-of-care nursing visit

  A full assessment, a home safety walk and a plan you help write.

  Medicare

• Medication reconciliation

  Every bottle checked against the discharge list.

  Medicare

• Wound and incision care

  Dressing changes and healing checks, with photos for your surgeon.

  Medicare

• Home safety walk-through

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

  Medicare

• Equipment setup

  Walkers, shower chairs and raised seats delivered and fitted.

  Included

• IV therapy

  Antibiotics and fluids at home, with line care.

  When ordered

• Caregiver orientation

  What to watch for, and when to call us first.

  Included

Days 8–45 · Getting stronger

• Physical therapy

  Strength, balance and walking, practiced on your own floors and steps.

  Medicare

• Occupational therapy

  Bathing, dressing and cooking made safe again.

  Medicare

• Speech-language therapy

  Swallowing, speech and memory after a stroke.

  Medicare

• Skilled nursing visits

  Symptom checks, teaching and adjustments with your doctor.

  Medicare

• Heart failure program

  Daily weights, swelling checks and a call-us-first plan.

  Medicare

• COPD program

  Breathing plans, inhaler coaching and oxygen safety.

  Medicare

• Diabetes care

  Insulin teaching, foot checks and meal plans.

  Medicare

• Home health aide visits

  Showers and personal care while skilled visits continue.

  Part of plan

• Fall-prevention program

  Balance training and a room-by-room safety check.

  Medicare

• Joint-replacement recovery

  Therapy from the first day after discharge.

  Most plans

• Stroke recovery

  Nursing, PT, OT and speech working from one plan.

  Medicare

• Catheter and ostomy care

  Changes, supplies and teaching.

  Medicare

• Lab draws at home

  Blood work collected at your table.

  When ordered

• Injections

  B12, blood thinners and others, given at home.

  When ordered

• Pain and symptom management

  Careful plans for pain, nausea and breathlessness.

  Medicare

Days 46–60 · On your own

• Self-management teaching

  Medications, symptoms and exercises, until you can do them without us.

  Medicare

• Discharge visit

  A final review of the plan and everything you've learned.

  Included

• Two-week follow-up call

  We call to check that the good ending is holding.

  Included

• Community connections

  Senior centers, Meals on Wheels, church rides and exercise classes.

  Included

• Recertification review

  If you still qualify and need more time, we work with your doctor to renew the plan.

  Medicare

All sixty days

• 24-hour nurse line

  A registered nurse with your chart, every night and weekend.

  Included

• Medical social work

  Medicaid, VA and long-term planning.

  Part of plan

• Telehealth check-ins

  Video visits for quick questions.

  Included

• Remote vital signs

  Blood pressure and weight sent to your nurse each morning.

  Included

• Physician coordination

  Your doctors updated after every meaningful change.

  Included

• Family meetings

  A sit-down with everyone whenever the plan changes.

  Included

• Spanish-speaking clinicians

  Nurses and therapists who can visit in Spanish.

  Included

• Equipment loan closet

  Walkers, shower chairs and commodes on loan.

  Free

• Veterans liaison

  Help coordinating with VA care in Dallas and Bonham.

  Included

• Respite planning

  Help finding a break for the caregiver who needs one.

  Part of plan