Health Systems Keeping your patients healthy at home.
Removing barriers to better health.
We use an advanced discharge planning methodology to transition patients from in-hospital care to their homes. Our team of pharmacists, nurses and community health workers provides education and support by identifying social barriers to keep your patients safe at home. Our teams evaluate your patient’s home and lifestyle to remove barriers hindering their path to better health.
Coordinating care through partnerships
We coordinate with referral sources to improve our patients’ quality of life and reduce healthcare costs through an integrated approach to care. We look at the big picture – working to remove barriers and educate and empower patients to put them on the pathway to better health.
Our services:
- Respiratory & HME
- Nutrition therapies
- Infusion pharmacy
- Community pharmacy
- Value-based care
Teach & Train
Our Clinical Transition Liaisons will meet patients in the hospital to them on what to expect as they transition from the hospital to their home. Our team will explain any maintenance required and will ensure each patient understands how to perform their prescribed therapy. Our teams will help coordinate with the patient’s home health organization to ensure there are no gaps in care.
Healthy at Home Program Criteria:
Diagnosis of congestive heart failure, acute myocardial infarction, chronic respiratory disease (COPD) or pneumonia
Exacerbation of this diagnosis resulting in at least 1 hospitalization, ER visit, or unplanned physician office visit within the last year
OR if the patient is already under Barnes Healthcare Services’ care
Our program includes:
- Pre- and post-discharge education from a clinician
- Successful transition from hospital to home
- Medication management
- Proactive patient engagement and education
- Care coordination within the home setting
- Care coordination within the home setting
- Early intervention to reduce future ER visits and hospital readmissions
- Community health worker involvement
- Pharmacy and nursing as needed
- Outcome reporting