Home Health

Home health care is a team effort. At James River Home Health & Hospice, no single clinician carries the full weight of your loved one’s recovery. Registered nurses, physical and occupational therapists, speech-language pathologists, social workers, and home health aides work in close coordination with each other and with your physician – each bringing a different lens to the same goal.

What makes this coordination meaningful is communication. Your care team shares information, adjusts plans together, and ensures that every visit moves your loved one in the same direction. When one discipline identifies something outside their scope, they bring it to the team. Nothing falls through the gaps.

Our team has served patients across Virginia for more than a decade, with subspecialty experience in orthopedics, neurology, cardiology, pulmonology, and complex chronic disease management.

Meet Our Home Health Care Team

Core skilled services address what your loved one needs clinically. Our specialty programs go a step further – building condition-specific protocols, closer monitoring, and deeper physician coordination around particular recovery goals and chronic conditions.

These programs are designed with one outcome in mind: keeping patients out of the hospital. Through structured clinical oversight, early identification of warning signs, and patient education that actually sticks, our specialty programs have a demonstrated track record of reducing avoidable readmissions.

Programs include:

• Orthopedics – structured rehabilitation following joint replacement, spinal surgery, and orthopedic injuries, built around your surgeon’s specific protocols
• Respiratory Care – designed for patients managing COPD and moderate to chronic respiratory conditions, with a focus on improving breathing function and reducing hospitalization episodes
• Cardiac Care – supporting patients recovering from cardiac events or managing heart failure, working alongside your cardiologist to monitor symptoms and reinforce long-term heart health
• Neurological Diseases – specialized management strategies for patients living with stroke, Parkinson’s disease, ALS, multiple sclerosis, spinal cord injury, dementia, and Alzheimer’s disease
• Complex Care – comprehensive support for patients with multifaceted conditions, including advanced chronic disease, wounds, cancer-related needs, and a history of frequent hospitalizations

Each program begins with a thorough clinical assessment and is adjusted continuously as the patient’s condition changes. Your physician is an active participant throughout.

View All Home Health Specialty Programs

1. A physician orders home health services. Your doctor, hospital discharge planner, or care coordinator initiates a referral. You are also welcome to call us directly at (855) 415-5744 to ask questions before a referral is placed.
2. A clinician completes a home assessment. A Registered Nurse visits your home, reviews your loved one’s medical history and current needs, and works with the ordering physician to develop a personalized plan of care.
3. Your care team begins. on your schedule. Visit frequency, disciplines involved, and specialty programs are determined by the plan of care. Our on-call clinical team is available 24 hours a day, 7 days a week, including nights, weekends, and holidays, should a concern arise between visits.

We work to begin care quickly following a referral. Our team coordinates closely with hospital discharge planners so that transitions home are as smooth and safe as possible.