Nurse-Led Clinical Recovery Continuum.
Our nurse-led clinical model is engineered to transition patients seamlessly from acute medical stability to independent wellness through 5 structured pathways.
Referral & Clinical Review
A comprehensive review of the hospital referral is conducted to ensure Sentinel is the appropriate level of care. Our team maintains close collaboration with hospital discharge planners, physicians, nurses, case managers, and MCOs to organize safe patient transit schedules.
Key Deliverables & Safety Milestones:
Admission & Comprehensive Nursing Assessment
Evaluates current medical condition, medication reconciliation, wound status, functional abilities, behavioral health needs, nutrition/hydration, fall risk, social determinants of health, and discharge planning needs upon arrival at our facility.
Key Deliverables & Safety Milestones:
Individualized Care Recovery Plan
A customized program that may include nursing oversight, medication management, wound monitoring, chronic disease support, behavioral health coordination, patient education, care coordination, transportation planning, community resource linkage, and housing stabilization.
Key Deliverables & Safety Milestones:
Recovery & Care Coordination
Continuous monitoring while maintaining communication with hospital partners, healthcare providers, and community organizations. Registered Nurses coordinate services to promote safe recovery, medication adherence, appointment compliance, and continuity of care.
Key Deliverables & Safety Milestones:
Transition & Community Reintegration
A structured transition plan is enacted to support long-term success through continued healthcare engagement, community resources, housing support, and follow-up services as patients return home.
Key Deliverables & Safety Milestones:
Traditional Discharge vs. Sentinel Respite Model
| Clinical Care Area | Traditional Discharge | Sentinel Respite Model |
|---|---|---|
| Post-Discharge Oversight | Self-managed care at home or shelter |
24/7 Supervised Registered Nurse oversight
|
| Medication Management | Unassisted pill management, high error risk |
RN reconciliation, education & daily sync
|
| Chronic conditions management | Selfcare |
Registered Nurse–led care management
|
| Readmission Prevention | High 30–day ER bounceback rate |
–38% reduction in avoidable readmissions
|
| Housing & SDOH Sync | Uncoordinated referral to external shelters |
Dedicated housing stabilization navigation
|
Ready to Implement the Clinical Recovery Model?
Partner with Sentinel Health Partners to improve care transitions, reduce 30-day hospital readmissions, and protect vulnerable patients.