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St. Tammany Health System

Transitional Home Care

St. Tammany Health System’s Transitional Home Care program supports patients after a hospital stay with personalized post-hospital home care, remote patient monitoring, and in-home or virtual visits from experienced clinicians. Specialized programs for heart failure and COPD help patients manage chronic conditions, promote recovery at home, reduce the risk of readmission, and provide peace of mind for patients and caregivers.

What’s next?

Our brand of world-class healthcare doesn’t stop after you’ve been discharged from the hospital.

Being discharged from the hospital to the comfort and familiarity of your own home is usually welcomed by most patients. But, with a number of tasks often required for proper healing and recovery to prevent re-hospitalization, it can also be stressful for you and your loved ones.

Thanks to St. Tammany Health System’s Transitional Home Care program, it doesn’t have to be.

With help from our team of specialists, we’ll follow your care after your hospital discharge. This will involve comprehensive home visits and virtual visits from our nurse practitioners and registered nurses. The goal: to ensure you continue to improve and avoid a return trip to the hospital, as well as to give you and your loved ones some welcome peace of mind.

Under the umbrella of transitional care are disease-specific programs aimed at treating chronic diseases such as heart failure, chronic obstructive pulmonary disease (CPOD) and sepsis. These care programs are tailored to provide focused care at home to bridge the gap between an inpatient stay and your usual care providers.

Please click on your program of interest below or call St. Tammany Health System’s Transitional Home Care team at (985) 871-5955 for help determining your next steps.

About remote patient monitoring

Remote patient monitoring uses digital devices such as a blood pressure cuff, pulse oximeter, scale and tablet to collect daily vital signs. These vital signs are monitored daily by a registered nurse to detect early warning signs of a CHF or COPD exacerbation.

Vital signs are transmitted to the St. Tammany Health System Transitional Care office and reviewed seven days a week. Any abnormal findings are address by one of our nurse practitioners.

A patients vital signs can be seen by the patient and their caregivers in MyChart app. Remote patient monitoring equipment is delivered to your front door and is a quick and simple set up.

Contact us at 985-871-5955 for questions or a referral to St. Tammany Remote Patient Monitoring.

COPD Program

Introducing St. Tammany Health System's Transitions of Care COPD Program

Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung condition characterized by airflow limitation and persistent respiratory symptoms, such as shortness of breath, coughing, sputum production and wheezing. These symptoms result from structural abnormalities in the airways (chronic bronchitis) and/or the alveoli (emphysema).

The highest incidence of COPD occurs among individuals who smoke or have a history of tobacco use. An estimated 16 million adults in the United States are affected by this condition.

Frequent exacerbations of COPD are a leading cause of hospital readmissions and can lead to long-term declines in lung function, deterioration in overall health status, and a reduced quality of life.

To address these challenges, St. Tammany Health System's Transitions of Care COPD Program offers a home-based, patient-centered approach focused on education, assessment, management and care coordination. The program includes home visits by nurse practitioners and registered nurses, telehealth consultations, and regular telephonic follow-ups to support a seamless transition from inpatient care to home recovery.

Post-Hospital Home Care

Our STHS brand of compassionate care doesn't stop at the hospital walls.

Services offered

  • Physical exam with our providers and nursing staff in your home for your convenience.
  • Medication review to ensure appropriate plan of care.
  • Medication refill as needed.
  • Treatment of acute and chronic conditions with expedited availability.
  • Ordering of diagnostic tests as needed.
  • Ordering and referring to home health, physical therapy, occupational therapy or other specialty providers.
  • Coordination of care, communication with your primary and specialty providers.
  • Advanced care planning.
  • Remote monitoring with daily vital signs reviewed by transitional care staff. (See below for more information on remote patient monitoring.)

Transitional care is a service offered by St. Tammany Health system to ensure a smooth transition from your hospital stay to your regular home life. When you are referred to transitional care, you will receive a phone call within 48hours of your discharge from the hospital. At that time your care team will coordinate home visits with a St. Tammany Nurse Practitioner and Registered Nurse.

These care team members will physically assess you in your home, review plan of care instructions, reconcile your medication regimen, and intervene with any issues or concerns you may have after discharge.

Most importantly, your transitional care team will be available for you as a safety net. You are encouraged to call your transitional care team with the promise of care management, effective communication with your usual care providers, and an empathetic ear on the other line.

Why you may benefit from transitional care:

Being hospitalized is stressful, and the return home can be just as taxing. When you leave the hospital, you will often be discharged with a new plan of care, new medications and a new specialty provider to follow up with.

Transitional care is available to help you navigate these changes and lessen the stress that accompanies a recent hospital stay.

Heart Failure Program

Introducing STHS's Transitions of Care Congestive Heart Failure Program

Heart failure is a lifelong condition in which the heart muscle can't pump enough blood to meet the body’s needs for blood and oxygen. Basically, the heart can’t keep up with its workload.

The prevalence and risk for heart failure is increasing with an estimated 6.7 million adults having the condition.

With this ever growing disease, St Tammany Health system has assembled a team of healthcare professionals to aid in the coordination, management, and prevention of heart failure (Heart Failure Program).

The Transitions of Care Heart Failure Program at STHS is a home-care-based program providing specialized care to patients with heart failure for 90 days after discharge from the hospital. Assessment, evaluation, management, prevention, coordination amongst specialties, and ongoing monitoring are at the core of the heart failure program with an overall goal of maintaining health and avoiding risk factors that may lead to hospitalization or poor health outcomes.

Meet the team

The Transitions of Care COPD program at St. Tammany Health System is a home-care-based program made up of trained professionals who provide compassionate, specialized care to patients with heart failure for 90 days after discharge from the hospital.

Meet the team

The Transitions of Care Heart Failure program at St. Tammany Health System is a home-care-based program made up of trained professionals who provide compassionate, specialized care to patients with heart failure for 90 days after discharge from the hospital.