Hospital-to-home transitions
Hospital-to-home nursing in Atlanta, arranged with your child’s discharge team before you leave.
The best time to arrange home nursing is before discharge, not after. We work with your child’s discharge planner, collect the orders and start the GAPP paperwork with you so care at home can begin as soon as possible.
Mon–Fri 9am–5pm · Toll free (877) 891-5222
What happens, in order
You call us
Ideally when the team first says “home nursing.”
We contact the hospital
With your OK, we talk to the discharge planner or case manager and request orders and records.
We file for GAPP
We prepare the application with you. See GAPP application help.
We match nurses
Nurses are trained on your child’s equipment and orders.
Care starts at home
An RN visits early to assess your child and finalize the plan.
What to ask the discharge team
- What equipment is coming home, and from which company?
- What training do I need to finish before discharge?
- Who signs the home nursing order, and who follows my child after discharge?
- Can you send the orders and discharge summary to our home care agency?
Be honest about the gaps
Across Georgia, approved nursing hours aren’t always fully staffed right away. We tell you which shifts we can cover, keep recruiting for the rest, and talk with you about Family Caregiver for the gaps.
Have this ready for the first call
- Your child’s age, diagnosis and Medicaid status (or that you’re applying).
- The name and phone number of the doctor who manages your child’s care.
- A rough picture of a normal day and a hard day.
- The hospital name, unit and the discharge planner’s name and number.
- The expected discharge date, even if it might change.
Hospital-to-home questions
When should I call a home nursing agency before my child is discharged?
As soon as the care team says home nursing is part of the plan. Nursing and GAPP paperwork take time, and starting early gives the best chance of shifts being ready when you get home.
Can my child leave the hospital without home nursing in place?
That’s the care team’s decision, and it depends on whether trained caregivers can safely cover every hour. Many hospitals require parents to be fully trained before discharge for this reason.
Who talks to the hospital, me or the agency?
Both. With your permission, we contact the discharge planner or case manager for orders and records. You stay in charge of decisions.
Related care and help
- Trach and ventilator care at home
Airway, suctioning and ventilator support on shift.
- Complex respiratory care at home
Oxygen, BiPAP, cough assist and breathing treatments.
- Pediatric RN home care
Registered nurses for assessments, care plans and the most complex shifts.
- Pediatric home nursing (RN and LPN)
Skilled nursing shifts at home, covered by GAPP.
- GAPP application help
We prepare and submit the GAPP paperwork with you.
- Conditions we care for
SMA, cerebral palsy, muscular dystrophy, brain injury and more.
- One Day of Care checklist
List everything you do in a day before the doctor visit.
Coming home soon? Call us now.
(404) 905-7699 Call (404) 905-7699- Hours
- Mon–Fri 9am–5pm. Closed Sat–Sun.
- Toll free
- (877) 891-5222
- Fax
- (404) 891-6466
- Office
- Ava Family Services, LLC
275 Interstate North Cir SE, Suite 200
Atlanta, GA 30339