How the Program Works

• Your Peoples Health patients being discharged from an inpatient stay can elect to be enrolled in the program and receive 60 days of at-home post-discharge care from an Elara Caring team of skilled nurses and therapists.
• There is no cost to the patient.
• An initial in-hospital visit may be conducted with the patient prior to discharge to perform a preliminary assessment and begin developing a plan for post-discharge care.
• Within 48 hours of discharge, the plan of care is completed and includes:
  • In-home nursing and therapy services based on needs and chronic conditions
  • Telehealth visits
  • Telephonic outreach
  • Home monitoring (blood pressure cuff, scale, etc.) if indicated
• The patient receives a thorough explanation from the Elara team of the discharge care goals, along with printed materials.
• The patient’s primary care provider is kept informed about all care coordination efforts, including the need for follow-up care and medication adherence.