Older adults often need additional support after a hospital stay. Without the right care, they may face complications that can lead to readmission.
VNS Health provides age-friendly care at home to support recovery, improve outcomes, and help patients stay safely at home.
Why Age-Friendly Care Matters After Hospital Discharge
After a hospital discharge, older adults face increased risks as they recover at home:
- Medication errors or confusion
- Wound care issues and infection, including sepsis
- Falls and mobility limitations
- Worsening chronic conditions
With the right support, medically complex patients can reduce their risk of readmission. VNS Health partners with you to support your patients’ recovery, prevent complications, and manage symptoms at home.
The 4Ms Framework in Action
Our Home Care teams use an evidence-based, patient-centered model called Age-Friendly Care. Developed by the Institute for Healthcare Improvement, Age-Friendly Care uses a “4M” framework as a roadmap for care to help improve patients’ health outcomes.
What Matters. At each home visit, clinicians ask: “What matters most to you?” This allows us to align care to each patient’s goals, such as:
- Recovery priorities
- Shared decision-making
Medicine. Clinicians review medications at every home visit. We:
- Make sure patients or their caregivers understand how and when to take medications
- Monitor effectiveness and side effects
- Coordinate with you and the pharmacy to prevent harmful interactions
- Confirm prescriptions are filled correctly
- Provide infusions and injections, and teach safe administration
Mobility. We assess and support safe movement through:
- Fall risk screening
- Coordinating physical and occupational therapy
- Home safety evaluations
Mentation. We monitor cognitive health by:
- Screening for delirium, depression, and dementia
- Coordinating behavioral health services as necessary
- Escalating care when concerns arise
Taken together, the 4M care model helps reduce ER visits and hospitalizations while improving patient satisfaction.
Comprehensive Age-Friendly Care at Home
VNS Health provides coordinated, age-friendly care at home for patients recovering after a hospital stay. Our teams support safe transitions, help prevent complications, and align care with what matters most to each patient.
Services we provide
For eligible patients, we offer:
- Skilled nursing
- Rehabilitation therapy (physical, occupational, and speech)
- Social work support
- Behavioral health care
- Advanced care planning
We tailor services to each patient’s clinical needs and recovery goals.
What you can expect when you refer to us
When you refer your patients to VNS Health, we:
- Provide skilled nursing follow-up after hospitalization
- Reconcile and monitor complex medications
- Manage cardiac, pulmonary, and chronic conditions after acute events
- Deliver wound care, IV therapy, and post-surgical monitoring
- Support patients at risk for falls or mobility challenges
- Deliver age-friendly, goal-aligned care at home
A multidisciplinary team with deep expertise
Your patients are supported by a multidisciplinary team experienced in caring for medically complex populations at home. This includes:
- Remote patient monitoring and telehealth support
- Clinical care managers
- Wound, ostomy, and continence nurses
- Registered dietitians and health coaches
- Caregiver support and coaching
- Transitional and advanced illness care planning
Our teams coordinate closely with you to reduce care gaps and improve patient outcomes.
Supporting Cardiac Patients
VNS Health has earned the American Heart Association’s Home Health Heart Failure certification, demonstrating our commitment to delivering evidence-based, high-quality care that follows AHA science.
Our goals:
- Offer coordinated, seamless care across disciplines and care settings, with a focus on safe transitions
- Reduce heart failure-related hospitalizations and overall health care costs through expert, specialized care
- Improve patient-reported outcomes, experience, and functional status
How We Support Referring Providers
We make the referral process simple and predictable. We’ll work closely with you to ease your patient’s transition to post-acute home care.
- Referral timing guidance. Recommended timeframes so patients can start care quickly
- Intake confirmation timeline. Clear timelines for referral receipt and next steps
- Ongoing communication. Regular updates on referral status, start of care, and patient progress
- Escalation support. Clear contacts for urgent questions or concerns
- EMR integration (if applicable). Secure exchange of referral and care information
You’ll know what to expect at each step of the referral process and throughout the duration of the patient’s care.
Quality and Accreditation
VNS Health Home Care has earned a 5-star quality rating from the Centers for Medicare and Medicaid Services.
We also hold AHA certification and CHAP Deemed Status, along with Age-Friendly Care at Home certification. This certification confirms consistent use of the 4Ms framework to improve outcomes and patient experience.
Referral FAQs
Find answers to common questions about referring your patients to VNS Health.
Partner with VNS Health
When you refer your patients to VNS Health, you gain a partner focused on preventing complications, supporting recovery, and helping patients maintain independence. We align with what matters most to each patient.