We like to have continuity of care with our patients. This means rounding on patients admitted to the hospital until they are discharged.
We along with the specialty consultants, hospital staff ( RN, case managers, physical therapists ) carve out treatment plan for the patients during their stay. We involve families in the patient care.
At the time of discharge, depending on the patient’s need a patient is either discharged home, to rehab facility or an Assisted living facility .There are other discharge options in special needs cases.
If a patient needs home care services after discharge, this can be arranged prior to patient being discharged. These services include home physical therapy, wound care, IV medications, blood draws etc.