Transitions in Care Continuum

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Making your path home easier

What Is the Transitions in Care Continuum Program?

The Norton Healthcare Transitions in Care Continuum (TICC) program is designed to help our patients move from Norton Audubon Hospital or Norton Brownsboro Hospital to a rehabilitation facility and, ultimately, back home. Our TICC team is here to support you and your family with compassionate and comprehensive care. We help reduce the stress that comes with being in the hospital, and we provide a safety net of helping hands to assist you as you navigate from one health care setting to another. Our physicians and nurse practitioners work together during your transition and will provide your primary care provider with up-to-date information about your care.

What Happens During My Hospital stay?

A transitional nurse practitioner will meet with you and your family at the hospital to discuss your medical needs. He or she will review your current medications, illnesses, physical therapy needs and care goals. A social worker also will meet with you and discuss community resources you may benefit from as you move from the hospital to the rehabilitation facility to home. The transitional nurse practitioner will ensure that the rehabilitation facility is prepared for your arrival.

What Happens When I Am Ready to Leave the Hospital?

When you are ready to move from the hospital to a rehabilitation facility, your medical records will be transferred so that your care can be streamlined. The transitional nurse practitioner will coordinate your care with the physician-led transition team, and a planning conference will be held to discuss the steps needed to get you back home.

What Happens While I Am at the Rehabilitation Facility?

At the rehabilitation facility, you will have physical, occupational or speech therapy, or a combination of the three. The physicians and nurses will manage your care 24 hours a day, seven days a week. Your clinical care team will meet weekly to discuss your progress and review the timeline for going home. A home health nurse will visit you and begin to prepare you and your care team for your discharge home.

What Happens When I Go Home?

Once you are discharged home, your Norton Healthcare transitional nurse practitioner and social worker (if needed) will visit you at home. During this visit, they will talk to you about your medical diagnosis, medications, therapy needs and primary care follow-up. The social worker can help with transportation, meal delivery or other community-based programs you may need. If you will have a home health nurse, the transitions team will coordinate your care with home health services. Finally, we will make sure you have an appointment scheduled with your primary care provider. Your primary care provider will play an important role in your ongoing care from this point forward. If you do not have a primary care provider, the transitions team can help you find one.

If you do not have someone to take you to the doctor or you do not drive, a Norton House Calls physician or nurse practitioner can come to your home.

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