Transitional Care

Often, without warning or planning, mom or dad are institutionalized in either a hospital setting, skilled nursing facility, or rehabilitation facility. Following a short or lengthy stay, the client must return home or transitioned into a long term care environment.  This transition can be a difficult and overwhelming time for older adults and their families.

PNP has a Transitional Care Program that offers innovative solutions and resources to assist you and your loved one manage a smooth transition.

Our Professional Nurse Care Manager will evaluate the client at home or in the facility, develop a plan of care following a comprehensive assessment, assist with discharge planning, and coordinate all needed care services prior to the client being transferred.

Relocation Support

Most older adults prefer to stay in their own homes and "age in place" as they grow older.  The challenges of aging, chronic and acute illnesses, physical and/or cognitive decline, or a crisis might force the family and older client into considering relocation to a more supportive environment. 

Professional Nurse Partners will assess the situation by conducting a thorough evaluation of the client and family's needs and assist all involved determine the level of care and appropriate living environment within their budget and personal preferences.

Benefits Of the Program

  • Registered Nurse Oversight

  • Improves Clinical Outcomes

  • Reduces health care costs

  • Decreases incident of re-hospitalization

  • Decreases risk for falls

  • Facilitates better communication with families, physicians and caregivers
  • 24 hour on-call Nurse Care Manager

  • Ongoing monitoring and assessment

  • Client/Patient centered care

This program makes a significant difference to the client as part of the continuum of care for those who need time and support following a hospital stay.

We have established relationships within our senior care community and are able to support your loved one's needs by assisting you in finding a new place to call "home" when it's time to transition to an assisted living facility.  

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