Transitional Care Programs and Services
Intensive Post-Acute Rehabilitation
Individuals entering rehabilitation are always unique, but their primary objective is typically the same – a return to health, home and what’s important in life, as soon as possible. At Touchpoints Rehab, part of the iCare Health Network, we understand.
Our innovative, personalized program is designed to accelerate the recovery process, so that patients can Get Well, Live Well and Be Well, faster, better and with fewer challenges than any traditional rehabilitation program. These programs are designed to optimize therapy, promote recovery, and provide ongoing quality of life for patients experiencing chronic and high acuity medical conditions.
What is Transitional Care?
Touchpoints Rehab is a leader in this field. Transitional Care uses a team of healthcare providers including nursing, respiratory and other staff to closely monitor a patient’s health status from setting to setting. This team will guide care from the hospital to the skilled nursing facility and into the home ensuring a smooth transition from one to the next. You will often see the same nurse or team member in the hospital, in the facility and following up after discharge to ensure success and avoid readmission to the hospital.
The Care Transitions team works with physician guidance and alongside APRNs, Physician’s Assistants and the entire staff of the skilled nursing facility. The team focuses additional focus and resources on patients with complicated medical conditions who are at risk for frequent hospital admission.
Care Transitions Team
- Heart Failure Nurse
- Regional Clinical Director
- Care Transitions Respiratory Therapist
- Multi-disciplinary clinical team
- Consulting physician specialists, PAs and APRNs
Addressing Frequent Hospitalizations
The program also addresses repeat hospitalizations by applying frequent lab work and assessment, integrated specialty care including pulmonary/respiratory therapy and sleep medicine, specialist consultation, clinical partnerships and more.
For patients with multiple hospitalizations the team will address their general state of health and wellness and improve their daily functionality. This will get them back home where they want to be and slow the tide of re-hospitalizations.
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Care Transitions Clinical Programs
- Congestive Heart Failure
- Chronic Obstructive Pumonary Disease (COPD) and other related pulmonary disease processes.
- Post open-heart surgery care.
- Affiliation or enrollment in Accountable Care Organization, Risk or Payment Bundle and/or at high risk for readmission.
Program Highlights
Some patients who have been hospitalized following these conditions may be encouraged to stay in a post-acute facility to regain their strength. Our network partnerships ensure that our patients receive rehabilitation services in close collaboration with their medical team within the hospital networks. The key features of this unique approach include:
- The Touchpoints Rehab team has been trained by the hospital network team. The clinical team follows their established protocols.
- Touchpoints Rehab has experienced physicians and physician extenders.
- The Touchpoints Rehab team includes a dedicated Director of Care Transitions who follows caseload patients through the course of their care, including after discharge home and provides additional, continuous clinical over- sight and support.
- The hospital and Touchpoints Rehab teams remain in continuous communication, working together to ensure a smooth transition. In addition, the hospital team remains informed on the progress of patients’ post-acute stays on a daily basis and continuing through discharge home.
- Once discharged, patients are reconnected with their primary care provider.
- Touchpoints Rehab staff are skilled in the delivery of all IV treatments and modalities.
Program Benefits
- Consultations and daily communication with the hospital team ensure continuity of care and optimal treatment decisions.
- Careful oversight of progress and a quieter, more personal environment are highly conducive to rapid improvements.
- Individually paced rehab programming enables faster recovery, stabilization and restoration of strength.
- Ongoing specialty evaluations
- Diagnosis-specific education for you and your family
- Healthy menus tailored to your diagnosis.
- Weight monitoring
- Physical, occupational and speech therapies
- Customized care planning
- Home support and discharge planning
- Weekly rounds by hospital practitioners
- IV Lasix, Bumex, Dobutamine and Milrinone therapies
- Weekly lab value monitoring
- Touchpoints Rehab locations in Bloomfield, Manchester, East Windsor and Farmington.
For more information, please call (860) 812-0788, email moc.nheraci@ofni or visit us online at www.touchpointsrehab.com
News & Updates
Discover the latest from our blog
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On November 14, 2024 the team at Trinity Hill Care Center celebrated iCare Health Network’s 25th Anniversary via Bavaria in the form of Oktoberfest! Residents and staff had an amazing day filled with fun and festivities. The day kicked off with a delicious German-inspired lunch featuring Bratwurst sausages, potatoes, and a decadent German chocolate cake for dessert. In the afternoon, Trinity Hill held a special award ceremony to honor their incredible staff members who have been with the c… -
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On September 19, 2024 the team at MissionCare at Holyoke celebrated iCare Health Network’s 25th Anniversary with a Wild Wild West themed bash. The party included a petting zoo, plenty of food and music and sunshine. Staff and residents went all out on the western garb. -
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On October 25, 2024 the team at Westside Care Center celebrated iCare Health Network’s 25th Anniversary with a Mardi Gras style party. All the details were covered down to the decorations featuring iCare CEO Chris Wright’s face. Or as the team put it, Westside “gets down the WRIGHT way”. -
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On October 23, 2024 the team at Silver Springs Care Center in Meriden celebrated iCare Health Network’s 25th Anniversary with a party theme of ‘Celebrating 25 Years of Cultural Diversity’. Silver Springs had a Caribbean food truck parked outside which everyone loved! We had music, cake, decorations, cultural desserts and different cultural food items, and drinks brought in by employees as well. Employees wore clothing from their culture as well. According to the Silver Springs … -
Please Accept our Thanks for Your Service -- Happy Veterans Day 2024
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On behalf of iCare Health Network, our care centers and entire staff, we would like to honor all of our nation’s veteran’s for all that they gave in service of our country. We celebrate the service of our Veterans with gatherings and group recognitions and celebrate their service and their sacrifice. There are dozens of veterans in every iCare facility as staff members, residents, vendors, families and others. On behalf of all of iCare, THANK YOU. -
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Fresh River Healthcare’s Therapeutic Recreation Director Jason Prevost and Food Service Director Janine Lancaster have been working hard to put together programs and events that are engaging, therapeutic and meet personalized sensory needs for all residents. This month they initiated “Bake My Day,” a program that enables residents in performing tasks that they might do at home. Baking allows them to control the taste, texture, and design of their product. In addition, Fresh River … -
Halloween Happenings Around the iCare Health Network, 2024
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Many Halloween and Fall-related events were taking place around the iCare Health Network last week. Residents and staff had a great time celebrating with food, music, decorations and activities. Check out the photos here! -
Parkville Care Center Celebrates iCare Health Network's 25th Anniversary with a Masquerade Ball
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On October 18, 2024, the team at Parkville Care Center put on a Masquerade Ball under the lights of the main patio to celebrate iCare Health Network’s 25th Anniversary. Residents, families, staff and guests had a wonderful time. The ball was complete with DJ, photo booth, dancing, hors d’oeuvres and a toast to the next 25 years! Great job, Parkville team! Check out our Facebook page for a video highlight reel from the Masquerade Ball.
