Transitional Care Management Services

HHP specializes in provision of physician-led, transitional care services delivered into the home during the transition of care from a hospital, managed facility, or group setting. Our goals is to provide excellent coordination of care and ensure each of our patients receives the support and aid needed to maximize recovery and improve quality of life.

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About Transitional Care Management

Personalized services that help patients move from one care setting to another

HHP delivers a set of services specific to each patients to help them move from one care setting to another, such as from a hospital to their home. The goal is to ensure patients receive the care they need to recover and reduce hospital readmission.

This includes follow-up appointments, medication management, and coordination with other healthcare providers -- typically a team of professionals, including specialists, home care, physical therapy, social workers, and case managers.

Transitional care is important because patients can experience new diagnoses, medical crises, or changes in medication therapy after being discharged from a hospital or other inpatient facility. Common causes of patient readmission are often caused by communication failures, procedural errors, and unimplemented care plans.

  • Transitional Care Management
  • Chronic Disease Management
  • Preventive Services and Care Gaps
  • Diagnostic Testing and Aid Equipment
  • Medication Management Services
  • In-Home Clinical Services and Support
Home Health Partners Services

Our Clinical Services

HHP provides clinical care services delivered in-home during the transition of care from a hospital, managed facility, or group setting. Our goals is to provide excellent coordination of care delivery to ensure each patient receives the support and aid needed.

Discharge Review and Physician Orders

Prior to leaving the facility, our providers review the patient discharge summary and coordiante home-based needs with our partners

Initial Telehealth and Provider Home Visit

An initial phone-based conversation with the patient or caregiver is completed and an in-home visit with the patient is scheduled

Medication Review, Diagnostics and DME

Patient needs are reviewed in depth on an individual basis to properly manage medications, additional diagnostics and supporting DME

Care Gap Assessment
and Care Planning

A health risk assessment and screening for care gaps is administered by nursing staff in order to create a comprehensive care plan

In-Home Aid Support
and Therapy Services

Ongoing coordination with a partner network of home-based aid and therapy services is managed to ensure patient needs are fully met

Regular Monthly Care Coordination Services

Ongoing communication with the patient and caregivers is delivered by a dedicated nurse to address needs as they change over time

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Care Goals and Objectives

Key Clinical Directives

HHP holds the following as primary guidance in our delivery model to ensure success in transition of patient care:

  • Ensure a smooth transition for patients between different healthcare settings through communication and transparency with all involved, including patients, caregivers, specialists and home health services
  • Prevent complications, improve patient outcomes, and reduce the risk of readmission through provision of coordinated care, medication reconciliation, preventive services, and caregiver support
  • Assessment and support of care plan treatment compliance, medication dosing adherence, and promotion of activities for self-management of health conditions through patient education
  • Establish and renew referrals for specialized care and therapy services, durable medical equipment, and assisting in follow-up to confirm patient needs are met with these services
  • Identify and communicate potential community services that patients may benefit from and arranging access to the services as appropriate according to need and eligibility

Home Health Partners

HHP provides physician-led transitional care services to patients in-home after discharge from a health system facility. Our goals is to provide excellent coordination of care and ensure each of our patients receives the support and aid needed to maximize recovery and improve quality of life.

Useful Links

Contact

Phone

(201) 275-0100

Email

info@hhp.care

Address

255 W Spring Valley Ave, Ste 205
Maywood, NJ 07607
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