At Patient Focus Physicians Associates, our physicians specialize in coordinating safe, effective care transitions that set patients up for a full and speedy recovery at home.       

Comprehensive Home Follow-Up Care

After hospitalization, our physicians provide:

• Thorough reviews of inpatient records and discharge instructions     
    
• Physical exams to assess recovery progress and identify any complications      
  
  
• Management of post-op pain, nausea, and other side effects       
  
  
• Adjustment of medications as needed   
  
  
• Diagnostic testing to rule out issues and monitor healing         
  
  
• Education on any new diagnoses, lifestyle changes, or self-care needs   
      
• Therapy referrals and recommendations for equipment or devices         
   

Close Monitoring and Support

• Frequent follow-up visits and contact during the first few weeks post-discharge  
     
• 24/7 availability by phone for urgent issues 
        
• Coordination with any rehabilitation services, home health agencies, or equipment vendors
  
  
• Guidance on preventing infections, managing incisions, and minimizing functional decline
       
• Recommendations for community resources and support services as needed     
      
• Assistance navigating insurance and facilitating referrals to specialists
                

Complication Management and Prevention       

• Identifying and promptly treating post-hospital complications like infections, blood clots, and internal bleeding  
  
  
• Adjusting medications to optimize healing and reduce side effects      
   
• Arranging tests or specialist consults for problems outside our primary care scope     
  
  
• Closely monitoring “red flag” signs and symptoms that may indicate a complication      
  
  
• Recommending lifestyle changes and self-care strategies to aid your healing and recovery 
    
• Educating family members and caregivers on what to look out for
  
  

Reducing the Risk of Readmission

• Detect and address any new or worsening symptoms before they necessitate hospitalization    
    
• Ensure medications are coordinated, up-to-date and taken as directed    
    
• Provide emotional support and encouragement to boost patients’ confidence in self-care       
  
  
• Close the communication loop with inpatient care teams to review treatment plans and reconcile any discrepancies
  
  
• Coordinate post-acute care including rehabilitation, home health, durable medical equipment, and outpatient therapy as needed    
  
  
• Establish contingency plans for managing setbacks and exacerbations of chronic conditions      
  
  

A Focus on the Whole Person

Our physicians consider all aspects of patient’s health and well-being:

• Physical: Through monitoring recovery, managing pain, and adjusting medications. 
      
• Emotional: By supplying reassurance, validation, and encouragement during a difficult transition period.   
  
  
• Social: With referrals to support groups, caregiver resources, and community programs when isolation is a risk.   
  
  
• Functional: Via recommendations for therapy, equipment, home modifications, and lifestyle changes to optimize independence.

As patients transition back home, we strive to make the experience as safe, seamless, and supportive as possible. Our goal is for each person to not just recover, but to thrive once again. Please contact us if you need comprehensive follow-up care and complication management services after hospitalization or surgery. We’re here to help you heal – and truly go home.