UPMC Visiting Nurses

The UPMC/Jefferson Regional Home Health Facility Case Management Program is currently in place at several assisted living facilities. For additional information, e-mail info@upmcjeffersonhomehealth.com.

Our purpose is to provide overall coordination of care, facilitate communication, and ensure continuity of care through assigned personnel known as facility case managers.

Facility Case Management Model

We have a diversified health care team to provide specialized care for patients of all ages, newborn to adult.


  • Improve overall outcomes through collaboration with facility staff and through coordination of care.

  • Educate patients and staff in order to contribute to positive outcomes through increased knowledge of disease process and treatment.

  • Serve as a bridge between patient, physician, facility, and home health.

  • Provide multidisciplinary care in order to assist the patient in reaching his or her full potential.

  • Continually work to improve the quality of life for the aging population.

Program Design

  • Assign a case manager to provide overall patient care and coordination of services.

  • Complete physical, psychological and social assessments (OASIS) on each patient.

  • Develop comprehensive plans of care for each patient.

  • Work with an interdisciplinary team to provide oversight and collaboration in patient care.

  • Participate in multidisciplinary care conferences in order to establish patient care plans.

  • Assess residents to determine whether they are eligible to participate in established disease state management programs, including Telehealth monitoring.


The facility case manager will have overall responsibility for the facility he or she is assigned to. Responsibilities include, but are not limited to:

  • admissions

  • direct patient care

  • coordination of care

  • communication

  • patient education

  • care conferences

Admission Criteria

All patients must meet the following conditions of participation in order to qualify for admission to the home health program. The criteria include, but are not limited to, the following:

  • must be homebound (if payor requirement)

  • require a physician order for home health services

  • require skilled intermittent care

  • need a responsible caretaker

For additional information, e-mail info@upmcjeffersonhomehealth.com.

Quality Care
We provide you with enhanced care with a treatment plan tailored to your health condition, environment, and level of recovery.

Compassionate Care
Our dedicated staff help you and your family cope with your condition and work toward your recovery.

Timely Care
We are fully staffed seven days a week to make home care visits, even on holidays when necessary. After normal business hours, a medical professional is always available to take your call.

Patient & Family Centered Care
We are committed to providing you with an exceptional home health experience by delivering and approaching care from the patient and family perspective.