To improve the safety of high risk patients during and after hospital discharge, Visiting Nurse Service provides a Transition Coaching program. Nurses and social workers teach patients the skills necessary to maintain and improve their health, and empower them to take charge of their well-being. It has decreased hospital readmissions by 25 percent and is now a UR Medicine standard of care.
Our professionals visit patients in the hospital and soon after discharge at home to:
- reconcile medications
- help the patient complete a personal health record
- ensure physician follow-up
- educate the patient about health indicators
Our visiting professionals also follow up with patients over the phone within the first thirty days after discharge.
Visiting Nurse Service of Rochester and Finger Lakes Visiting Nurse Service—UR Medicine’s home care agencies—provide transition coaching for patients at Strong Memorial, Highland, Nicholas Noyes, Geneva General and F.F. Thompson hospitals. Each day we receive census reports from these facilities, and approach patients who meet the eligibility criteria directly at their bedsides to discuss enrollment. A physician referral is not required; however we do send a courtesy fax to primary care physicians notifying them of their patients’ participation.