An RN who has access to the hospitals and meets with patients who are transitioning home. The NTN visits include:
- In-person visit made to the patient at bedside.
- Answers questions about home health services, coverage and expectations.
- A comprehensive medication reconciliation is completed to determine need/formulary substitutes and patient’s ability to afford medications.
- Ability to set up appointment to provide medications delivered to the patient’s home/ financial help with donut hole and generic substitutions.
- Assist patient with Primary Care Physician follow up appointment made prior to discharge and updates PCP on hospital course for continuity of care.
- Specialist appointments made if necessary.
- Access need for/utilization of community and other resources such as transportation, private care services, Meals on Wheels, etc.
- NTN will follow up by phone with high risk patients after home health admission to decrease risk for rehospitalization. We have a 24-hour agency nurse hotline.