Transitional Care

Transitions Between a Hospital, Rehab, Skilled Nursing Facility and Home

Returning home after a discharge can be both exciting and unnerving. Aware Senior Care understands the challenges patients face, and with our highly-skilled RN team, we are equipped to help make the transition seamless.

Once home, our goal is to help clients:

  • Increase medication compliance
  • Reduce hospital readmissions
  • Relieve client and family concerns

Our RNs follow the discharge plan outlined by the client’s physician, working in tandem to promote healing and recovery. On the day of discharge, an Aware Senior Care RN will:

  • Review client medications
  • Perform a home safety review
  • Organize medications into pillboxes upon request
  • Review discharge orders/restrictions
  • Coordinate care with home health services (if home health has been ordered)
  • Assign a personal care or companion aide (if services are requested)

Our goal is to promote recovery through compassionate and knowledgeable care, while working with the client and family to ensure safety and compliance.

The Welcome Home Services package includes up to two hours with an RN in your home on the day of discharge. Visits can be scheduled between 9:00 A.M. – 3:00 P.M. on weekdays or after business hours (including weekends).

To learn more about our RN managed transitional care services, contact Aware Senior Care today at (919) 436-1871. Let us help you get home safely and regain your independence!