Care Transitions Management

How It Works
Once the referral is received, we immediately begin sourcing full-time staff. Prior to discharge from the facility, patients will meet with an internal office representative and a lead nurse from the Transition Team to detail how the program works. Once the patient transitions home, we’ll employ our nurses to ensure full coverage until the permanent nursing staff can be identified. 

Transition Team nurses provide care for all authorized hours in a home during a provisional period between 1-90 days. During this time, our office staff will be recruiting to identify full-time, replacement home healthcare nurses. The new caregivers will have an opportunity to train and shadow in the home with the Transition Team caregivers prior to working independently with the patient. Once the replacement nurses are trained and have a schedule, the Transition Team are then phased out of the home. 

This supplemental care model improves quality by placing highly-trained temporary staff in the home, shifting to equally-qualified long-term staff. Our team reduces time spent in the hospital waiting for agencies to secure full staffing of authorized hours prior to discharge. With the Maxim model, full staffing can be secured on the initial call to us. If there is an occasional fill-in need for a long-term caregiver,our Transition Team will step in to cover any gap shifts.