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A caregiver comforts a patient sitting in a chair. A caregiver comforts a patient sitting in a chair.

How Right Transitions Can Help Discharges

With the CMS adding pressure through the SNF Value-Based Purchasing Program, we recognize that the need to keep your hospital readmission rates at an all-time low is more critical than ever. We also recognize that it is more difficult than ever to provide your patients with the intense, one on one care that they often require for the entirety of their hospital discharge transition.

If you were included in the 73% of penalized Skilled Nursing Facilities under the SNF VBP Program last year you will be pleased to know that we can help. Our goal is always to keep our clients out of the hospital and we have developed a proven process to be of assistance.

We welcome you to ask us about our Right Transitions program. This program is going through a rapid expansion and we are delighted to introduce you to it. Right Transitions is a program that can be offered to patients and their families as a peace of mind tool. With the program, the patient will have a consistent, well-trained caregiver(s) with them to offer one on one assistance and attention throughout their transition, how ever long that may be.

There are a variety of options ranging from 4 hours to 24/7 care which can be tailored to fit your patient’s exact needs. This can include transportation, discharge coordination, facilities introductions with other residents and/or facility activities, one on one care and MUCH more. We can also fill gaps that you may need improvement on based on your quarterly feedback reports from the CMS, provide your patients with their families with an added sense of security, and monitor your patient on a one to one, individualized basis around the clock.

In addition to personalized care, our caregivers are required as part of their clock-out process to input if the patient has had a “change in condition”. They are trained to monitor a client at their baseline and promptly notify a Right at Home Client Care Coordinator if anything is different than usual. A change in condition can range anywhere from, “the client seems different than usual, they are agitated” to “there has been a change in mobility, experiencing an unsteady gait”. Once the Care Coordinator is notified of the change, we promptly notify all necessary parties (the facilities designated nurse, social worker, or patient’s family for example).

We adopted our “change in condition” process after partaking in a Harvard Medical Study which implemented a systemic process for observing, reporting, and monitoring changes in our clients and proved to prevent avoidable hospitalizations, improve health outcomes, and in turn, lower healthcare costs.

We’re here to help!  We would love the opportunity to come and meet with you to answer any questions that you may have and to further discuss the benefits of you being able to offer Right Transitions to your patients and their loved ones.

Contact us for more details about Right Transitions

Need help right now? Call us anytime at

(508) 668-8001

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