Primary and Symptom Management Care Services
Transitions offers the highest quality of end of life care, symptom management, and primary care services. We specialize in supporting individuals and families who are facing the physical, emotional, social, and spiritual challenges confronted when dealing with terminal and chronic illnesses. Paramount to our philosophy is to ensure that our patient is experiencing their final transition on their own specified terms — in comfort and with dignity. In our care, our main objective is always to maximize patients’ comfort and quality of life.
With Transitions, Primary and Symptom Management Care is always about living. That is why we provide patients with a comprehensive care plan led by a dedicated interdisciplinary team.
At Transitions Care, our primary care services bring the doctor to you. Primary care involves day-to-day healthcare where the provider acts as the patient’s first point of contact in the health system. Unlike most primary care providers, Transitions Care is equipped to provide advanced symptom management and has the capabilities necessary to optimize care coordination while maintaining strong and unique relationships with our individual patients. Our goal is to allow home-bound patients to continue receiving regular physician services and to prevent any future hospitalizations through our symptom management capabilities.
Symptom Management Care
Transitions symptom management care is specialized, family-centered, chronic care management for individuals with a chronic or advanced illness, focused on pain and symptom management to enhance quality of life. Unlike typical palliative care, Transitions symptom management services go above and beyond other providers. Our teams take a holistic treatment approach that addresses both medical and psychosocial needs, including pain management, social and emotional counseling, as well as community service support. Our main focus is preventing repeated hospitalizations, more effectively treating long term illness, managing suffering, and focusing on the quality of life for all patients. Symptom management is appropriate for people of any age and in any stage of a chronic or advanced illness.
The Transitions Difference
Primary Care and Symptom Management Care
At Transitions, we go the extra mile to maximize our patients’ comfort related to symptom management. Our teams – which include physicians, advanced practice nurses, social workers, and other specialists – collaborate with our patients and their families to create an individualized care plan. Once the care plan is in place, we commit to uncompromising demands of symptom management and palliative care that set us apart from our competition: 24/7 patient monitoring, extensive social worker and counseling resources, care services provided in the comfort of their own home, and a visit latency of under 48 hours upon a patient request for a visit.
We aim to empower patients and families by providing the tools and support necessary to embrace life. We don’t focus on the finality of your illness; we focus on the practical side of living. Above all else, our efforts aim to ensure that the final stage of life comes with the most comfort, peace, and happiness possible.
Symptom Management Team Capabilities:
Advanced Practice Nurse (APN) available to come onsite of facility
APN outpatient consultation in your own home
Registered Nurse (RN) 24/7 emergency symptom management visits
Social Service Support
Common Symptoms Treated:
Shortness of Breath
What are the benefits of Primary Care?
Our primary care services include management and treatment of acute and chronic diseases, medication management, health promotion, disease prevention, and immunizations, all in the comfort of your home. These services allow for patients to have direct access to a doctor even in a situation where they are homebound, with 24/7 remote monitoring to ensure that any change in a patient’s condition is addressed.
What are the benefits of Symptom Management Care?
There is a growing recognition in the health care community that repeated hospitalizations can be unnecessary and traumatic when dealing with chronic symptomatology. The trend toward community based services, palliative care, and symptom management is guided by this trend, as it has been proven to prevent repeated hospitalizations and more effectively treat long term illness. In addition, our care provides advanced symptom management services that ensure a high quality of life and support both the patient and family throughout the course of care.
At Transitions, we provide the highest quality symptom management to our patients. And, if hospitalizations can be reduced – our goal of allowing the patient to live a more comfortable and happy lifestyle will likely be fulfilled.
We love hearing from you!
“Transitions has been so kind to our mother the past few months. They were there for our father four years ago as he declined. The nurses, social worker and chaplain have been in frequent contact, offering support all the way. Thank you.”
When is it Time ?
Patients may receive Transitions primary and/or symptom management care if they are progressing through a chronic or advancing illness or are homebound due to medical circumstances. Our goal is to manage symptoms and control the progression of an illness in order to ensure patient comfort and quality of living. In addition, patients may receive curative treatment in conjunction with our primary or symptom management services regardless of the diagnosis.
A variety of different diseases and symptoms are treated by our care teams. Here are some of the most common factors and diseases processes that may indicate that your loved one is ready for in-home primary care or symptom management services:
Changes in Healthcare Conditions:
Diagnosed with a new illness
Post Surgical Rehabilitation
Common disease processes that may benefit greatly from Primary and Symptom Management Care services:
Alzheimer’s and other Dementia causing diseases such as
FTD, Lew Body, Huntington’s Disease and Primary Progressive Aphasia
Chronic Heart Failure (CHF)
Chronic Obstructive Pulmonary Disease (COPD)
Multiple Sclerosis (MS)
Who Pays for Symptom Management Care?
Primary Care and Symptom Management are covered by Medicare Part B, Medicaid, most private insurance benefits, as well as Veterans Affairs (VA) benefits. Benefits and eligibility are checked upon patient referral. Services covered include:
Registered Nurse Emergency Symptom Management Visits
Durable Medical Equipment and Supplies
Spiritual, emotional, social, dietary, and other counseling services
Music Therapy, Massage Therapy, and other ancillary services
At Transitions, we strive to go above and beyond for our patients. In addition to the benefits outlined above, we also provide our patients with following services at no extra cost:
Assistance when filling out Medicaid (Public Aid) applications
Aid in finding community resources for social and emotional support
Life Enrichment services to make the later part of life all about living
Discussing family dynamics and help navigating these dynamics from a licensed professional
Seamless transitions from palliative care to hospice care if the patient sees a significant decline in their health
We love hearing from our patients and their families
“Thank you for the wonderful care you gave to our mother and to us. I so much appreciated the calls with frequent updates on our mom’s condition.”
RevUp Remote Patient Monitoring and Health Coaching
RevUp is a software used by Transitions that offers palliative patients a personal Health Coach that will help them successfully achieve their goals by managing and reporting on aspects of day-to-day health. This information is constantly monitored by Transitions’ Symptom Management Team, providing our patients with live, up-to-date information on their health and current outlook. This allows us to visit with patients in a timely and efficient manner when they need us most, as well as help Transitions monitor our patients even when we are not present – furthering our promise of 24/7, 365 palliative and primary care.
If you are a Transitions patient and need to sign up for this service or just want to learn more about remote patient monitoring, please click the following link: getrevup.com/transitions-home-medical-group/
Any questions? Contact us at 844.244.1066.