Who This Program Is Designed For
The Complex Care Program provides ongoing support for patients and families managing one or more of the following:
- Congestive Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- Dementia
- Liver or Kidney Failure
- Wounds
- Cancer
- Frequent Hospitalizations
If your loved one has been managing one of these conditions, or cycling in and out of the hospital without a clear resolution, this program may be the right next step. Our care coordinators will help you understand whether it is a fit before any commitment is made.
What to Expect from the Complex Care Program
The Complex Care Program follows a defined structure so your family always knows what is happening and who to call.
- A call from a Registered Nurse within 24 to 48 hours of admission. Within the first two days of enrollment, a Registered Nurse contacts your family directly.
- Regular check-in calls every two to four weeks. Throughout the program, your care team maintains consistent contact between visits, proactively checking in on your loved one’s condition.
- Support to prevent rehospitalization. Frequent hospitalization is often a sign that something in the post-discharge support structure is not working. The Complex Care Program addresses that directly.
- Transitional care built around your individual goals. Care in this program is not designed around a generic discharge checklist. It is built around what your loved one needs.
A Full Continuum of Care
One of the most meaningful aspects of the Complex Care Program is where it sits within the full range of services James River Home Health & Hospice provides.
If your loved one’s condition stabilizes, the program supports a clear, coordinated transition to a less intensive level of home health support. If your loved one’s condition advances toward a point where comfort and quality of life become the primary goals, our team will help you have that conversation and, when the time is right, support a seamless transition to hospice care.
You will not be left to navigate that transition alone or start over with a new provider. James River Home Health & Hospice provides both home health and hospice services, and the same commitment to coordinated, compassionate care runs through both.
Learn more about our hospice services
Frequently Asked Questions
- How is the Complex Care Program different from standard home health? Standard home health addresses the skilled care needs of a primary diagnosis within a general plan of care. The Complex Care Program adds a defined touchpoint structure including an RN call within 24 to 48 hours of admission and regular check-in calls, along with a higher level of multi-condition coordination and a specific focus on preventing rehospitalization.
- Does my loved one need a specific diagnosis to qualify? Eligibility is based on clinical need and physician orders, not a single qualifying diagnosis. Our care coordinators will help you assess fit during the initial conversation.
- My loved one keeps going back to the hospital. Can this program help? That pattern is one of the clearest signals that the Complex Care Program may be appropriate. We cannot eliminate risk, but we are built to address it more comprehensively than a standard plan of care can.
- What if my loved one’s condition continues to decline? If your loved one’s condition advances beyond what home health can adequately address, your Nurse Navigator will help you understand the options clearly.