HHQI Agency of the Month: February 2014

 

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California, Nevada, Idaho, Utah & Wyoming
 
Rocky Mountain Care has been providing health care since 1990. Living happier. Living Healthier. Living more independently. These are the goals of Rocky Mountain Home Care. Through our staff of skilled and compassionate people, it is our mission to provide quality, individualized service to strengthen an independent lifestyle, promote dignity, and enhance our patient's ability to remain in their own place of residence. 
 
As a company we are constantly assessing and strengthening our post-acute care continuum. With the use of multiple tools we incorporate a hospitalization risk assessment, a fall risk assessment, and pain assessments, among others to reduce re-hospitalizations. Part of our processes to improve patient care and reduce hospitalizations is to include the patient’s primary-care physician with a weekly summary of progress on the patient’s conditions, addressing any concerns or questions the doctor raises. In some cases the case manager even attends follow-up appointments with the patient to the primary care doctor. We also focus on medications the patient is taking. If errors are detected or if the regimen is confusing or impractical, the case manager helps the patient and family and caregiver to communicate their questions and concerns to the relevant health care provider.
 
The case manager also educates the patient about warning signs (red flags) that the patient's condition may be worsening and helps him or her to understand when to call the physician or other health care provider. Structured visits and phone calls by the case manager promote safe transitions home during the critical first month following a hospitalization. Every visit and phone call, patients are strongly encouraged to call home health with questions at any time. We have found that our patients have a much better chance to regain their independence and prevent re-hospitalizations through this program.

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