Averyn Care
Hospital-to-Home Plan
Hospital-to-Home Plan — Susan
First-week coordination plan (non-clinical) • Day 0: Wed, Jan 7, 2026 • Prepared Tue, Jan 6, 2026
🧭 Transition snapshot
One screen| Item | Details |
|---|---|
| Supported person | Susan Saro (preferred name: Susan) |
| Primary family contact | Jordan Saro • 1-440-555-0111 • jordan.saro@email.com |
| Local helper | Maria Saro • 1-216-555-0102 |
| Backup family contact | Ben Saro • 1-330-555-0144 |
| Discharge date/time | Tue, Jan 6, 2026 • 6:00 PM ET |
| Pharmacy | City Pharmacy — 123 Main St, Cleveland, OH 44115 • 1-216-555-0987 |
| Home health start | Willow Pathways Home Health • expected Thu, Jan 8 (confirm time window) |
Supported person
Details: Susan Saro (preferred name: Susan)
Primary family contact
Details: Jordan Saro • 1-440-555-0111 • jordan.saro@email.com
Local helper
Details: Maria Saro • 1-216-555-0102
Backup family contact
Details: Ben Saro • 1-330-555-0144
Discharge date/time
Details: Tue, Jan 6, 2026 • 6:00 PM ET
Pharmacy
Details: City Pharmacy — 123 Main St, Cleveland, OH 44115 • 1-216-555-0987
Home health start
Details: Willow Pathways Home Health • expected Thu, Jan 8 (confirm time window)
👥 Ongoing care team & contacts
Directory| Role | Name / organization | Phone | Email / notes | When to use |
|---|---|---|---|---|
| Averyn navigator | Brianna Cole | 1-844-283-7961 | family.support@averyncare.com | Coordination, scheduling, household updates |
| Primary care clinician | Alan Hughes, MD | 1-216-555-1234 | Parkside Primary Care Group | Questions; follow-up Tue, Jan 13 • 10:30 AM |
| Pulmonology (lung specialist) | Aisha Rahman, MD | 1-216-555-4321 | Parkside Pulmonary Clinic | Follow-up Tue, Feb 10 • 2:00 PM |
| Home health nurse | Willow Pathways Home Health | 1-216-555-7654 | Intake line | Start-of-care visit; education/checks if ordered |
| Physical therapy (home) | Summit Pathways Therapy | 1-216-555-7655 | Scheduling | Walking and stamina plan; safety coaching |
| Occupational therapy (home) | Summit Pathways Therapy | 1-216-555-7656 | Scheduling | Daily activity safety (showering, kitchen tasks) if ordered |
| Pharmacy | City Pharmacy — Main Street | 1-216-555-0987 | Pickup/delivery questions | Medication questions; refill timing |
| Transportation | North Shore Medical Transport | 1-216-555-9876 | Schedule rides | Rides to appointments if family cannot drive |
Averyn navigator
Name / organization: Brianna Cole
Phone: 1-844-283-7961
Email / notes: family.support@averyncare.com
When to use: Coordination, scheduling, household updates
Primary care clinician
Name / organization: Alan Hughes, MD
Phone: 1-216-555-1234
Email / notes: Parkside Primary Care Group
When to use: Questions; follow-up Tue, Jan 13 • 10:30 AM
Pulmonology (lung specialist)
Name / organization: Aisha Rahman, MD
Phone: 1-216-555-4321
Email / notes: Parkside Pulmonary Clinic
When to use: Follow-up Tue, Feb 10 • 2:00 PM
Home health nurse
Name / organization: Willow Pathways Home Health
Phone: 1-216-555-7654
Email / notes: Intake line
When to use: Start-of-care visit; education/checks if ordered
Physical therapy (home)
Name / organization: Summit Pathways Therapy
Phone: 1-216-555-7655
Email / notes: Scheduling
When to use: Walking and stamina plan; safety coaching
Occupational therapy (home)
Name / organization: Summit Pathways Therapy
Phone: 1-216-555-7656
Email / notes: Scheduling
When to use: Daily activity safety (showering, kitchen tasks) if ordered
Pharmacy
Name / organization: City Pharmacy — Main Street
Phone: 1-216-555-0987
Email / notes: Pickup/delivery questions
When to use: Medication questions; refill timing
Transportation
Name / organization: North Shore Medical Transport
Phone: 1-216-555-9876
Email / notes: Schedule rides
When to use: Rides to appointments if family cannot drive
✅ First 72 hours checklist
High-signal- Confirm medication pickup/delivery; sort meds into a simple organizer (Morning / Evening).
- Confirm home health start-of-care visit time window.
- Confirm first home physical therapy visit date/time.
- Confirm whether occupational therapy is ordered; if yes, schedule the first visit.
- Verify walker fit and that it is placed where Susan will use it.
- Confirm transportation plan for primary care follow-up (Tue, Jan 13).
- Set a short daily check-in routine (10 minutes) for the household.
💊 Medication plan (plain language)
Avoid jargon- Time-limited medication: antibiotic course ends Tue, Jan 13, 2026 (last dose).
- “As needed” medications are optional; use only if symptoms match the label and the discharge paperwork allows it.
- If anything is unclear on the medication list, call the primary care office or the discharging team for clarification.
🗓️ Day 0 (Wednesday) rhythm
Fridge-friendly
Day 0 tracker: Use the separate one-page “Day 0 Tracker” for a fridge-friendly checklist of meds and tasks.
- Morning: breakfast + morning meds; short safe walk; quick notes (breathing/energy).
- Afternoon: confirm home health timing; rest; fluids; short walk if tolerated.
- Evening: evening meds; set tomorrow’s meds out; write down any questions for the primary care visit.
📅 Week 1 milestones
What’s coming- Thu, Jan 8: home health start-of-care visit expected (confirm time window).
- Within 3–5 days: first home physical therapy visit expected; occupational therapy if ordered.
- Tue, Jan 13: primary care follow-up at 10:30 AM.
- Averyn updates: end of Day 1 and again after the first home health visit.
📄 Disclaimer
ScopeThis is a non-clinical coordination plan. It does not replace discharge instructions and does not provide medical advice. For urgent or emergent concerns, contact the clinical team or call 911.