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.
Your caption text here
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
-
The entire iCare team is excited to celebrate National Skilled Nursing Care Week (NSNCW), also known as Nursing Home Week. The week is an annual observance held in May, dedicated to honoring the contributions of nursing home employees and recognizing the strength of nursing home residents.NSNCW 2023 embraces the theme Radiant Memories - A Tribute to the Golden Age of Radio. The theme embraces a time when the airwaves resonated with captivating stories and melodies. More than nostalgia, &… -
The entire iCare team is excited to celebrate National Skilled Nursing Care Week (NSNCW), also known as Nursing Home Week. The week is an annual observance held in May, dedicated to honoring the contributions of nursing home employees and recognizing the strength of nursing home residents. NSNCW 2023 embraces the theme Radiant Memories - A Tribute to the Golden Age of Radio. The theme embraces a time when the airwaves resonated with captivating stories and melodies. More than nostalgia, … -
National Nurses Week begins each year on May 6th and ends on May 12th, Florence Nightingale’s birthday. Nurses Day and Week promote nursing professionals for their dedication and commitment to advancing the health care field, while also raising awareness of the challenges they face. It is an opportunity to thank nurses for providing high-quality care to those in need every day of the year. This year’s theme, “Nurses Make the Difference,” honors the incredible nurses who embo… -
On April 30, 2024, the team at Silver Springs Care Center held a retirement celebration for Carmen Mallet, a Cook in the Food Service department, who retired from Silver Springs after 42 years of service. Carmen worked as a first shift Cook in the center since the days that Silver Springs was known as Royal Crest, with a start in March of 1982! -
iCare Health Network is pleased to announce that Renee Cole has joined the iCare team as the Director of Specialty Programming and Strategy. In her new role, Renee will be overseeing the implementation, design, educational frameworks and overall strategy for iCare’s range of specialty programs within its care centers. Renee brings significant knowledge and experience in special project management and as a licensed nursing home Administrator. Her role will be vital in enhancing and … -
A graduate of Western Governors University, Emily has eight years of nursing experience as an RN, primarily in long term care facilities due to her love for the geriatric population. She started her nursing career in Massachusetts until moving to Connecticut in 2020 where she found her nursing niche for infection control and wound care at her previous organization. -
I could not be prouder and more humbled of what iCare Health Network has become. By our calculations, in the over 9,000 days since April 1, 1999, we have proudly served and cared for over 30,000 residents. In 2024, we are a leading provider of skilled nursing and long-term care in New England, we enrich lives day in and day out, and we have distinguished ourselves across the country as an innovator and groundbreaker. Together, let us embrace the opportunities of the next 25 years of iCare… -
Francis Lijadu and Mirja Tupas Join iCare, Leading Heart Failure Program and Complex Care
March 22, 2024
iCare Health Network is pleased to announce that Francis Lijadu and Mirja Tupas have joined the iCare clinical team. Francis re-joined iCare in December 2023 as a Regional Clinical Director overseeing Education, Infection Prevention and Transitional Care, including Touchpoints Rehab’s signature heart failure and pulmonary programs. Mirja joined Francis’ team as a Transitional Care Nurse overseeing the direct care, transitions through the care continuum and success of residents on t…
