OnPointe At Home’s multi-generational experience across the healthcare continuum gives us an unmatched and intimate understanding of each patient and their specific needs.

Our team uses an all-inclusive intake process and follows precise protocols in order to learn about each patient’s individual journey. Understanding where they’ve been and where they want to go enables us to best help them with where they are now. Our Transitional Care Method – which includes a group of transitional nurses who closely monitor each patient – helps our patients and their families understand what to expect from us at each step in the process of their care, based on their individual health management plan.

The Professional Services provided by OnPointe At Home are part of the Medicare program called Transitional Care Management which was created in 2013. OnPointe At Home’s Transitional Care Management helps patients manage their healthcare needs following a discharge from: an Inpatient Acute Care Hospital, Inpatient Rehabilitation Facility or Hospital, Long Term Care Hospital, outpatient observation, partial hospitalization, or Skilled Nursing Facility.

Unlike many other home healthcare agencies, OnPointe At Home’s program is unique because we are able to provide these professional services and a team that includes a nurse practitioner and a transitions coach who work together to support each patient by helping them develop four self-care management skills.

These skills include:

  • Medication management
  • Recognizing and responding to red flags that could indicate a worsening conditions
  • Scheduling and preparing for follow-up care
  • Taking ownership of a core set of personal health information

During a 30 day period, the team works closely with the patient to help them attain these skills and the independence they need to continue living at home while experiencing a better quality of life.

As part of the Continuum of Care that we take pride in, the Transitional Care Management method illustrates that no matter what a patient’s home healthcare needs are, OnPointe At Home is prepared to provide expert, experienced, professional services in an empowering manner.