360 Care Coordination by Nexus ensures successful outcomes long after individuals discharge
Continuous care from referral to discharge — and beyond
Too often, patients leave care facilities in a stable condition, only to be rehospitalized after discharge. We identify individuals with particularly complex needs and provide training, support, and assistance to busy caregivers. In doing so, 360 Care Coordination by Nexus facilitates the transition from hospital to home, ensuring successful outcomes long after patients leave – because we’re committed to mending minds.
Decades of caring for individuals has led Nexus to creating this special
Depending on patient and caregiver needs, additional support may include:
- Early screening of candidates upon referral and admission to identify challenging situations that would hinder progress
- Master treatment planning during patient stay to address potential challenges after discharge
- Home evaluations to assess living conditions and durable medical equipment needs
- Post-discharge calls to check on medication usage, ensure patients are attending follow-up appointments, and answer caregiver questions
- Surveys that allow caregivers to identify challenges and request guidance
- Spot visits to check on caregivers and patients
- Facilitation/Coordination of outpatient care
- Follow-up calls with community providers, such as outpatient physicians and programs
- Collaboration with residential treatment facilities and therapeutic foster homes to ensure continuity of care
- Coordination with schools regarding Individualized Education Program (IEP)
- Communication and coordination with payors
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