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For Discharge Planners

Care coordination starts on the day of the patient's’ admission. The process of transition to your home safely is started on Day 1 of hospitalization. Coordination is important to retain smooth transition. For any questions, please call our office.

For Nurse Practitioners/Physician’s Assistants

You play the central role in care coordination. You will call the patient within 2 days of hospital discharge to set up an appointment time. The appointment varies between day 3 and day 7, and must be within day 7 according to Medicare guidelines.

As patients’ primary care transition provider, your responsibility is to make sure the medications are all updated, the patients have the medication, if they need we will call in prescriptions, communicate with home health nurse, physical therapist, occupational therapist, and speech therapist, as well as the medical social worker.

Also responsible for communicating with patients’ primary care provider and other consultants as need be.

Home Provider and Paramedic Collaboration

In case of medical emergencies that can be safely treated at home we work with EMS/911/Paramedics to treat you at home so that your need to visit emergency room is minimized and thereby saves you money in your medical care.

Home Health Nurse/Physical Therapists/Occupational Therapists

If you are a home health nurse, your responsibility in addition to taking care of patients is to also to communicate promptly and clearly with the transition care provider and patients’ other consultants as need be. If any clarification is needed, please call the office.

Message to Primary Care Providers

Patient’s’ primary care providers remain unchanged. If the patient has no primary care provider, we will help them to acquire one. We help patients to get appointments with primary care providers if needed. All patients are seen by their primary care providers as scheduled. All patients return to their primary care provider’s office as appointed.

For Consultants

Our responsibility is to coordinate patients’ care. As a patient’s consultant, please feel free to call us and voice your concerns and questions. If a patient is not keeping their appointments, please notify us. Make sure your secretary calls our office to notify us about a patient who was supposed to follow up with you, but did not.

USBD Community Paramedic Program

Creating community paramedics through our specialized program is our future project. We are communicating and collaborating with multiple existing paramedic workforce to create a community paramedic certification course. Such a paramedic will be specially trained to participate in future transition care programs. The goal is to to create a workforce who will be able to work in conjunction with housecall providers to reduce readmission, improve patient care and reduce cost of medical care.

USBD Internship Program

Clinical Internship: ARNP/PA Students

Non-Clinical Internship: Health Science Graduates
 

We offer internships for Nurse practitioners / Physician assistants and also for health science graduates, providing them with real world experience through participation and management. Our goal is to create a quality workforce to work in future transition care programs.