Supporting continuity of care through in-home nursing assessments, clinical monitoring, medication support, wound care, and post-discharge follow-up.
Appropriate referrals
- Recent hospital discharge
- CHF/COPD monitoring needs
- Frailty or functional decline
- Frequent ER utilization
- Polypharmacy and medication coordination needs
Filling the gap between discharge and follow-up
Many older adults experience challenges transitioning safely from hospital to home. Medication changes, delayed follow-up appointments, caregiver uncertainty, and evolving clinical needs can contribute to avoidable complications and repeat emergency department visits.
Integrity Senior Care provides private RN-led support designed to complement existing healthcare services and support continuity during recovery and ongoing care.
Emergency and acute care nursing experience
Founded by Payal, RN, BScN, Integrity Senior Care is informed by years of emergency and acute care nursing experience. Frequent exposure to hospital readmissions highlighted the need for additional nursing oversight during the transition from hospital to home, particularly for seniors with complex medical needs.
What we provide in the home
A simple, clinician-friendly path from referral to first visit
Integrity Senior Care works collaboratively with physicians, nurse practitioners, specialists, and community care providers to support continuity of care and timely communication regarding changes in client condition. Support may also be provided for patients living with advanced or progressive illness who would benefit from nursing symptom monitoring, medication oversight, family education, and continuity-focused follow-up within the community.
Contact Integrity Senior Care
Reach out by secure form, email, or phone to begin a referral. We accept referrals from physicians, NPs, discharge planners, and social workers.
Discuss Patient Needs
Share the diagnosis, discharge summary, medication list, and relevant clinical notes so we understand the situation.
Arrange Consultation
We review the referral and arrange an in-home nursing assessment based on clinical needs and scheduling availability.
Ongoing Communication
Concise clinical communication continues as appropriate to support continuity of care.
Download the referral form
Complete the form and return it by email. For urgent referrals, please call directly.
Send a family our way
When a referral becomes urgent at the family level, point them to a private consultation. We will take it from there.