Professional Home Health Care Services includes a broad range of care and support services for those who are recovering from a hospital stay, who are disabled, chronically or terminally ill and need medical nursing, social, therapeutic treatment and/or assistance with the essential activities of daily living.
Services we provide include, but not limited to, medication management, home safety evaluation, balance and fall prevention training, Alzheimers/dementia and cognitive impairment care.
To ensure a smooth transition across the care continuum, transitions of care typically involve multiple individuals across many settings. Our Care Transition Coordinators collaborate closely with discharge planners, care managers to prepare patients for what to expect in each setting and equips patients with the knowledge and tools required for successful self-management.
A registered nurse (RN) conducts an in-home evaluation to assess your needs. The RN works closely with your physician to develop a plan to support you in your recovery or disease management and will coordinate your care so you can remain safely in your home.
Therapy & Rehabilitation
Patients may require in-home rehabilitation services after being discharged from a variety of health facilities, including hospitals (after an early discharge from orthopedic surgeries, including total joint replacement or orthopedic repair of fracture and/or other surgeries), rehabilitation facilities, skilled nursing facilities, and doctors’ offices.
Medical Social Work
Our Social workers help people deal with some of life’s most difficult challenges, including: physical illness, disability, mental health issues and socio-economic limitations. Our social workers collaborates with other community organizations, including Councils on Aging; elder and protective services; home care organizations; hospitals; nursing homes; and assisted living facilities, in order to ensure optimal care for our patients.
Telehealth gives care teams the capability to monitor and coach high risk, chronic patients helping them improve their ability to manage their own condition. Care plans are tailored for the unique needs of each patient, delivering a personalized experience for patients. The Natick VNA’s telemonitoring system monitors patients’ blood pressure, pulse, weight, and blood oxygen levels enabling clinicians to make timelier care decisions.
ComfortCare / Palliative Care
ComfortCare is home-based palliative care delivered by the Natick Visiting Nurse Association’s team of certified specialists who work collaboratively to help patients manage their pain and other troubling symptoms. It addresses a patient’s psychological, emotional, and spiritual well-being, as well as their physical symptoms. Patients can still pursue treatments while under palliative care.
Rx Drug Assistance
MetroWest Meds, a program of the Natick VNA is designed to help eligible uninsured and under-insured individuals receive prescription medications at no cost or at a discounted rate. It is supported by the MetroWest Health Foundation, The Boston Scientific Foundation, and other grants and donations.
Your Care, Your Choice
After a hospital stay, many patients require continuing care in their home. Medicare requires all hospitals and medical facilities to 1.) Inform patients of their right to choose a post-hospitalization provider, such as a home health agency or nursing home; 2.) Provide the patient with a list from which the patient may choose a provider; and 3.) Disclose any agency that it has a financial interest in. Any facility that fails to explain this completely, or otherwise seeks to limit patient choice violates numerous Medicare regulations that explicitly guarantee beneficiaries the right to obtain services from any institution, agency or person that is a qualified Medicare provider. It’s your care, it’s your choice.
Return to Home
Our team of Care Transition Coordinator nurses (CTC’s) are vital in care coordination for newly referred patients and patients on service who have been hospitalized. The team remains an active member of the patient’s care team from admission to discharge working with medical professionals, the patient and their caregivers to foster communication and promote effective and efficient care. Care Transition Coordinators perform home safety evaluations, participate in discharge planning meetings and provide courtesy visits on the day of discharge if needed. Their main focus is to advocate for the patient.