Skilled Nursing Following Discharge Agency List

One aspect of the Wisconsin PATH ALONG models comprehensive approach focuses on the need for skilled nursing post discharge.  Are there tasks that will require the help of a skilled nurse in the home setting.  This is communicated as:

Hospital nurse     (transition)     Home care nurse

Dynamic component: Nursing summary completed

Rationale: a comprehensive nursing approach to recovery helps prevent rehospitalization

The primary role of a skilled nurse is teaching the patient and family about the tasks that will need to be performed to maintain health.  The hospital nurse will go over the nursing summary with the patient and family prior to leaving the hospital setting.

Should the patient need additional skilled nursing in the home setting, hospital staff should be able to help schedule this.  Often the patient and family will be presented with a list of Medicare certified skilled nursing agencies that can make home visits.  The skilled nursing visits are scheduled according to the patients need.  Skilled nursing visits usually involve a new medical diagnosis, with medication changes, or dressing changes.  Here the nurse is teaching the patient and family how to recover in the home setting.

A skilled nursing agency is not assigned to home visits to perform ADL's and IADL's.   Bathing, dressing, eating, meal prep, medication reminders, scheduled toileting, dressing, walking, mobility, transfers, are all performed by a supportive care agency (www.homecarepath.com ).  This can be confusing for the patient and family who may perceive that the skilled nurse will be assigned under Medicare to make lengthy home visits and fill this additional need for the dwelling. 

This is where the Wisconsin PATH ALONG model communicates to the population being served the important difference in the service that will be performed in the home setting.  Sending a patient who needs help with 2 or more ADL's or IADL's with just skilled nursing is not the best approach to coordinating care that will result in a readmission free recovery.

The take home message is always review the nursing summary prior to discharge from an inpatient setting.   Question if your at home needs will involve skilled nursing and supportive care and how those needs will be adequately met upon discharge. 

 You are cordially invited to download your free PATH ALONG app today

http://appsmakerstore.com/appim/j6kcdet8xvwk4s


 Home Care Path  www.homecarepath.com and the Wisconsin PATH ALONG model deliver an advanced supportive care service.  Helping seniors in the home, with clinic visits, at the hospital, nursing home and assisted living facility.  Helping seniors downsize with a move in to an adult child's home. 2013 rates are 20.00 per hour.  Simply call 608-432-4286 to schedule an interview.  We can be there when you are working.  We accept long term care insurance.  Services can be tax deductible.  Help with resources and the transition from private payment to public funded programming.  Valuing home and human life