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An RN who has access to the hospitals and meets with patients who are transitioning home.  The NTN visits include:

  1. In-person visit made to the patient at bedside.
  2. Answers questions about home health services, coverage and expectations.
  3. A comprehensive medication reconciliation is completed to determine need/formulary substitutes and patient’s ability to afford medications.
  4. Ability to set up appointment to provide medications delivered to the patient’s home/ financial help with donut hole and generic substitutions.
  5. Assist patient with Primary Care Physician follow up appointment made prior to discharge and updates PCP on hospital course for continuity of care.
  6. Specialist appointments made if necessary.
  7. Access need for/utilization of community and other resources such as transportation, private care services, Meals on Wheels, etc.
  8. 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.
In-hom nurse hapily chatting with an elderly gentleman.

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