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Apollo Transition of Care (TOC) for Seniors Program

Being discharged from the hospital to home after a prolonged hospital stay, an ICU stay or a surgical procedure can be a complex, confusing and difficult transition for elderly individuals. Hospital admissions often include a change in your functional abilities and overall health. The risk of after-discharge complications and hospital readmission is usually higher for individuals aged 60 years and above.

The Apollo Transitions of Care for Seniors is a unique, first of its kind program that has been developed by Dr. Aarthi Kannan (Geriatrician) in collaboration with Apollo Hospital Bannerghatta Road. Our vision, through this program, is to optimally prepare you as an older adult for a safer and more seamless hospital discharge and to provide you with a short-term holistic approach from a geriatric specialist team at home after discharge. Our TOC team consisting of our Geriatrician and senior nurse will initially visit you in the hospital to assess your overall health prior to discharge and then visit you once at home after discharge. These visits are scheduled to occur during your hospital-to-home transition to ensure that your recovery process is on track.

The TOC for seniors program is designed to:

  • monitor your recovery after discharge
  • help you regain your strength, wellness and function
  • offer you more clarity with medication changes and new medications
  • provide you with information and coordination regarding all your specialist doctor appointments
  • assess whether you may have additional needs such as nursing and rehabilitation/physical therapy at home

 

Who can enroll with the Apollo Transition of Care for seniors program?

You can enroll with the Apollo Transition of Care for seniors program if you are 60 years or older and meet ALL of the following criteria:

1) If you are being discharged home from Apollo Bannerghatta Hospital
2) If you live within a 5 km radius of Apollo Bannerghatta Hospital
3) You have one or more chronic medical conditions or have a diagnosis such as cancer that makes you more susceptible to complications
4) You had an ICU stay or a prolonged (7 days or more) hospital stay during this admission

 

Services included in 2-week TOC for Seniors package:

  • Initial Geriatrician and health manager (nurse) consultation in-hospital for an extensive geriatric evaluation prior to discharge. This will guide safe discharge practices and counsel the patient and family on resources they might need at home after discharge
  • Follow-up visit by Geriatrician and health manager (nurse) at home after discharge to assess patient’s overall condition, to foresee, prevent and manage specific health issues that may arise, and guide caregivers/family members on recovery goals
  • Counselling and guidance to family members on keeping the patient well at home
  • Personalised guidance on nutrition
  • Personalised guidance on activity, rehabilitation and regaining physical strength
  • 4 home-visits by our physiotherapist to guide you on specific exercises and strength training which will help you gain your strength through rehabilitation
  • 2 home visits from our medical social worker to guide you and your family through counselling and to provide you with psychological support upon discharge
  • Referral/guidance to avail additional services such as:
    A) Physical therapy for post-discharge rehabilitation, strength and balance training, assessment for assistive devices such as walker/cane
    B) Skilled nurse for bed sore/wound care/urinary catheter care, intravenous antibiotics at home
    C) Home health aide/attender as per requirement
  • 2 independent health manager (nurse) visits during the two week period to monitor recovery and address any additional requirements for ongoing medical care, to coordinate and maintain your primary specialist and other specialist appointments
  • 1 pharmacist visit to guide you with your medication changes and to help you keep your medication list up to date as much as possible

Kindly note:

The Apollo TOC for Seniors Program does NOT provide emergency or urgent health services, and is NOT an on-call service. Appointments are pre-scheduled at a time of mutual convenience between the patient and our TOC team, and are designed to provide non-urgent and non-emergent routine specialised health care through these home visits. We are available on the phone between 9 am to 7 pm Monday to Friday to help you schedule your appointment.

If you are experiencing a health-related emergency or have an urgent need to see a doctor, please seek care at the earliest at Apollo Bannerghatta Hospital emergency room/casualty or at an emergency room closest to you.

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