Subacute at Home Program

Assists with medication management, self-care education, symptom control and management, vital sign monitoring, IV therapy and nutrition support, and wound, ostomy, and continence care.

Creates personalized home exercise plans to improve strength, mobility, and balance, while also promoting safety and independence.

Recommends strategies and exercise plans that enhance independence and functional abilities.

Improves communication and cognitive skills and reduces the risk of aspiration or choking.

Helps with daily activities, including personal care, mobility support, and vital sign monitoring as ordered.

Enhances patient care and prevents medical emergencies by allowing healthcare provides to track vital signs in real-time.

Most insurance companies cover the cost of skilled care at home. However, the patient’s insurance benefits may vary based on the policy they hold. In some cases, the patient may have a co-pay. The discharge planner and homecare consultant will help the patient or caregiver to get this information.

The first visit may take up to two hours. The average visit lasts 40 to 60 minutes. Patients can expect a team member to:

• Check vital signs (i.e., blood pressure, temperature, heart rate, breathing)
• Make sure patients and caregivers understand when and how to take medicines.
• Teach patients and caregivers to care for wounds or IVs.
• Develop an exercise plan to build strength and improve balance.
• Follow infection prevention measures.
• Instruct patients and caregivers on how to keep bad symptoms under control.
• Provide companion-level conversation and encourage maximum patient participation in activities of daily living.

After the first home visit, the patient and caregiver will work with our healthcare team to determine the necessary number of weekly visits based on individual needs and provider recommendations. As the patient’s health improves, visits will gradually decrease.

• Doctor/provider visits: A MedStar Health physician or advanced practice provider will conduct in-person or telehealth visits at least weekly.
• Nursing visits: On average, a nurse will visit two to three times per week.
• Therapy visits: Patients will receive physical therapy (and occupational/speech therapy, if ordered) for 45-60 minutes, three to five days per week, in addition to provider and nursing visits.
• Aide visits: Home health aides are available more often during the first few weeks of the program, based on individual needs. Aides assist with personal care.
• Nutrition and meals: Patients will receive a nutritional consultation and may qualify for Meals on Wheels (daily delivery or weekly frozen meal options).
• Remote Patient Monitoring: This technology helps track health conditions and detect early signs of concern. Patients are expected to use the devices provided to take daily vital sign readings. The readings are automatically sent to a remote team of nurses for review.

To enhance patient care and prevent medical emergencies, our Remote Patient Monitoring system allows healthcare providers to track vital signs in real time. Here’s what to expect:

• Kit delivery: Patients receive a free remote monitoring kit (tablet, blood pressure cuff, pulse oximeter, and scale).
• Daily monitoring: Patients take vital readings each morning, which are automatically sent to a remote nursing team.
• Nurse monitoring: Nurses review readings and will contact patients if there are concerns or missed readings.
• Return process: Patients must return the kit after completing the program using a pre-paid shipping label.

To participate in the program, the patient must:

• Have a dedicated caregiver: A caregiver must be present to assist with medical needs when the healthcare team is not available.
• Stay reachable: Answer phone calls, texts, and voicemails promptly so the home care team can schedule visits.
• Complete daily remote patient monitoring: Log into the provided tablet daily to record vital signs (blood pressure, pulse oximetry, weight) at the same time each morning after using the bathroom. Respond to calls, alerts, and messages from the remote monitoring team.
• Have internet and a smartphone: Be willing to use these for virtual visits.
• Engage in self-care: Participate in personal care or have a caregiver assist as needed.
• Ensure a safe environment: Home care team members must feel safe during visits. They may leave if conditions are unsafe, including: harassment, verbal abuse, violence, illegal drugs, unsecured weapons, or loose pets.
• Communicate updates: Inform the team of any changes, including phone number, address, condition, medications, treatments, hospital admissions, or doctor’s appointments. The patient or caregiver should notify the team to reschedule or cancel a visit.

An associate from our MedStar Health Home Care team will contact the patient or caregiver to plan a home visit to occur on the day after discharge from the hospital.

During the 30-day program, one of our Subacute at Home Doctors and/or providers will oversee the patient’s care and visit either in-person or by using virtual video chat technology. A patient care summary will be sent to the patient’s primary care provider on a regular basis. The provider will also communicate with the Home Care team and write orders to meet the care needs of each patient. At the end of the program, the provider will transition care back to the primary care physician.

Patients will receive a Patient Guide folder with more details during the first home visit.