For many patients, being discharged from the hospital isn’t the end of their medical journey. Patients often require continuing care that takes place in the home. That’s when the UF Health Shands HomeCare team steps in. “HomeCare is a service provided to individuals who are recently discharged from the hospital and need ongoing care,” said Anthony Clarizio, UF Health Shands HomeCare executive director. “The skilled nurse, the physical therapist, the occupational therapist, the speech language pathologist, the medical social worker and the home health aid can all visit a patient at their home to support their success after hospitalization.”

With 160 health care professionals and 28 administrative support staff members, the team handles an average of 600 cases at any given time and serves patients across 12 North Central Florida counties.

They provide care for patients who no longer require acute care services but have medical or therapy needs, patients with chronic conditions and/or patients with high-risk health factors that could lead to readmission. To support the care provided in the home, the team also uses telehealth technology to monitor patients remotely.

The HomeCare team empowers patients to maintain an independent lifestyle at home. A recent example was its important role in the follow-up care of conjoined twins Savannah and Scarlett after they were separated and returned home from UF Health Shands Children’s Hospital.

“One of HomeCare’s missions is to assist patients and caregivers in achieving their health care goals,” said Christine Knowles, M.S.N., R.N., COS-C, HomeCare’s clinical practice director. “It’s very gratifying to know that the education, support and care our team provided aided the twins and their parents’ success, along with the success of all of our patients.”

Skilled nurses educate patients about new diagnoses, medication management and lifestyle choices. They provide wound and catheter care and assist with infusions, feeding tubes and ostomies.

Physical therapists work with patients to help them regain strength and range of motion through exercise. They help patients prevent falls and provide training for use of crutches, wheelchairs and other assistive devices.

Occupational therapists help patients adjust to their home environment. This can include retraining of everyday living tasks; balance training for dressing, bathing and self-care; and providing home safety evaluations.

Speech therapists offer speech and language training; evaluate patients for swallowing problems and communicative disorders; and provide assistance and training following surgery.

Medical social workers help patients plan for the road ahead with counseling, advance directive assistance, information about palliative care, transportation planning and community resource education.

Home health aides assist patients with a variety of day-to-day tasks, including bathing, light housekeeping, meal preparation, dressing, vital sign monitoring and personal care.