Fain's Private Duty
Fain's Private Duty Home Care is a nationwide private duty operator built on 17 years of New Jersey home care operating experience. New Jersey is our first launch market.
SERVICE TIER

Post-hospital recovery

Post-hospital recovery is the composite service that runs from the discharge window through the recovery arc, pulling in RN supervision, CHHA personal care, and companion presence in whatever mix the plan of care requires. FAINS runs the arc under a single Registered Nurse Supervisor of record and the same weekly transparent invoicing that governs every tier of The Fain Standard.

Minimum credential: Team including RN Supervisor plus CHHA and companion as needed
Starting rate: See tier that applies
Shift minimum: Four hours (per The Fain Standard pillar 3)

What post-hospital recovery care actually covers

Post-hospital recovery is not a single-tier service. It is a composite that combines the RN Supervisor role, one or more of the FAINS shift tiers (companion, CHHA, skilled nursing, or live-in), and active coordination with the discharging hospital and with any concurrent Medicare home health benefit, over the arc of the recovery period. The tier that applies at any given shift is the tier the plan of care specifies for that shift, and the mix changes as the recovery evolves.

The service exists because the highest-risk period of a serious hospitalization is not the hospitalization itself. It is the first 30 to 60 days at home. Most avoidable re-hospitalizations happen in that window, and most of them happen for reasons that a continuous private duty presence can address: medication reconciliation missed, ambulation not sustained, fall risk not managed, follow-up appointment missed, warning signs not caught, home safety changes not implemented. A private duty presence in that window does not replace the medical team. It gives the medical team a working surface inside the home during the days when the plan of care is most likely to slip.

Families call for post-hospital recovery in a specific set of scenarios. A discharge after a serious surgical procedure with a rehabilitation arc. A discharge after a stroke or cardiac event where the client is coming home with new limitations. A discharge from a skilled nursing rehab facility to home. A hospice-transition discharge where the family is choosing to bring the loved one home and needs continuous private duty presence around the visiting hospice team. The mix of tiers and the shape of the arc differ across those scenarios; the operating discipline is the same.

What a typical case looks like

James, 79, lives with his wife Anna in a two-story colonial in Basking Ridge, Somerset County. He underwent a cardiac valve replacement at an academic hospital in Newark. Nine days in the hospital, three days in the step-down unit, and a scheduled discharge home under the discharging hospitalist's care coordination plan. James came home with a new medication regimen (six meds, three of them new), a lifting restriction that ruled Anna out for transfer help, a moderate fall risk through the first four weeks, and follow-up appointments scheduled with the cardiology team, the PCP, and a Medicare home health agency for physical therapy and skilled nursing intermittent visits over the following six weeks.

Their daughter Elena, who lives in Chatham, called FAINS on a pre-license waitlist inquiry the day the discharge date was set. The FAINS RN Supervisor coordinated with the hospital case manager on a discharge-day handoff, did an in-home assessment on the discharge day itself, and wrote a plan of care that phased across three arcs.

Week one and week two: two eight-hour CHHA shifts a day, covering the morning wake-up, medication window, ambulation session, bathing, meal preparation, and the mid-day and evening transitions. Anna kept the overnight. The Medicare home health nurse visited twice a week for wound assessment and lab draws. The physical therapist visited three times a week. The FAINS RN Supervisor did a bedside check on discharge day, on day three, on day seven, and on day fourteen.

Week three through week six: one eight-hour CHHA shift a day plus a four-hour companion presence in the afternoon, as James regained ambulation confidence and Anna's sleep improved.

Week seven forward: step down to companion presence three afternoons a week, aligned to Anna's own respite schedule, as the case matured into a maintenance arc.

When the license issues, cases like James's will run under the tier rates published on the pricing page, billed weekly by tier, with the RN Supervisor holding the arc from discharge day through the maintenance transition.

What FAINS commits to for post-hospital cases

Post-hospital recovery is the tier where every one of the seven pillars of The Fain Standard is doing work at the same time, because the arc pulls in every operating discipline the framework encodes.

Every post-hospital case has a Registered Nurse Supervisor of record whose involvement is denser during the discharge window than at any other point of a FAINS case. The RN coordinates with the discharging team, writes the plan of care, credentials the assigned shift staff against the plan, and holds the clinical thread through the recovery arc. The 60-day supervisory visit cadence tightens to 30-day for post-hospital cases.

Every shift caregiver, whether CHHA or skilled nursing, is license-verified against the NJ Board of Nursing registry before the first shift and re-verified monthly. Post-hospital cases often draw on the deeper end of the roster because the acuity is higher and the clinical demands are more specific.

The four-hour minimum shift applies to every hourly shift in the post-hospital arc. Most discharge-window shifts run longer than four hours because the transition-period care tasks cluster together, but the four-hour floor is honored the same as every other case.

Weekly transparent invoicing runs Monday through Sunday. When the tier mix changes across an arc (skilled nursing shifts in week one, CHHA shifts in weeks two through six, companion shifts in the maintenance phase) the invoice itemizes each shift at the correct tier rate. The family sees the arc clearly on the paper.

The chemistry-matched commitment matters especially in post-hospital cases because the caregiver relationship is being established at the highest-stress moment of the recovery. A wrong match discovered on day five is worse in a post-hospital arc than in a maintenance case. The matcher proposes candidates, the family interviews before the first shift, and swaps happen without penalty in the first week.

The 24-hour cancellation window applies both ways, adapted for the discharge-window pace. Coverage caregivers are pre-identified for post-hospital cases so an unexpected primary-caregiver absence does not translate into a coverage gap during the highest-risk period.

Post-hospital care is private pay and private insurance only. The concurrent Medicare home health benefit for intermittent visits is a separate service running through a Medicare-certified agency. FAINS does not bill Medicare or Medicaid. Families who need Medicaid-covered continuous personal care in the post-hospital arc are referred to a fit-for-purpose provider.

What post-hospital care does NOT do

Post-hospital recovery does not replace the discharging medical team, the primary care physician, the cardiologist, the surgeon, or any specialist. FAINS is the continuous private duty presence at home. The medical decisions belong to the physicians.

Post-hospital recovery does not include physical therapy, occupational therapy, or speech therapy in the FAINS scope. Those therapies are delivered by licensed therapists through Medicare home health agencies or through private-pay therapy practices. The FAINS RN Supervisor coordinates the schedule.

Post-hospital recovery does not include emergency response. If a clinical situation on shift crosses the threshold that requires 911, the shift caregiver calls 911. Private duty is a continuous-care model, not an emergency-response service.

Post-hospital recovery does not include prescription writing, refill authorization, or dose adjustment. The RN Supervisor reads the discharge medication list, verifies it against what is actually in the home, flags discrepancies to the physician, and coordinates any needed correction with the prescriber.

How the intake works for post-hospital cases

Three steps, with the fastest possible clock among all FAINS tiers.

Step one is the initial call, often placed while the client is still in the hospital. The FAINS intake line hears the discharge plan, names the tier structure that is likely to fit the arc, and schedules the RN Supervisor's assessment. In some cases the assessment happens at the bedside in the hospital on discharge day; in most cases it happens in the home immediately after discharge.

Step two is the RN Supervisor's assessment. The RN reviews the discharge paperwork, contacts the discharging team when needed, verifies the medication list against what is physically in the home, walks the home for post-discharge safety changes, meets the primary family caregiver, and writes the plan of care with the arc phasing already sketched.

Step three is the chemistry match, expedited. The matcher proposes candidates whose skills fit the opening tier of the arc and whose temperament fits the client, coordinates a pre-shift interview even when the interview happens on discharge day, and confirms the caregiver's arrival for the first shift. Because post-hospital cases are time-critical, the FAINS matcher works from a pre-identified roster of caregivers who have current availability for a discharge-window start.

Common questions

How quickly can FAINS start after a hospital discharge?
The FAINS operating target is a plan of care in the family's hands within 48 to 72 hours of the discharge conversation, with the first shift in the home in the same window when the case allows. The RN Supervisor takes the initial call, does an in-home or in-hospital assessment on the same day or the next day, writes the plan of care, and coordinates the first shift. The specific timing depends on the caregiver match and the family's readiness. The published target is a discipline, not a slogan.
Can FAINS coordinate directly with the discharging hospital team?
Yes. The FAINS RN Supervisor is the clinical point of contact who reaches the hospitalist, the case manager, the discharging physician, and any home health agency running concurrent Medicare intermittent visits. That coordination is part of the tier, not a separate billed service.
What is the typical staffing mix for a post-hospital case?
It depends on what the discharge picture actually looks like. A post-surgical orthopedic case might open with a mix of RN supervisory presence in the first week for medication regimen coordination, CHHA shifts for personal care and ambulation through the fall-risk window, and a step-down to companion care as the client regains independence. A post-stroke case might open at the skilled nursing tier for the first month and step down through CHHA to companion over three to six months. The RN Supervisor scopes the arc at intake and revisits the mix every 30 days for post-hospital cases.
How does post-hospital care work alongside Medicare home health?
Many post-hospital cases run a concurrent Medicare home health benefit for intermittent skilled nursing visits, physical therapy, occupational therapy, and speech therapy through a Medicare-certified agency. FAINS provides the continuous private duty presence (CHHA shifts, companion shifts, or skilled nursing shifts) around those intermittent visits. The FAINS RN Supervisor coordinates the schedule so the home health therapy visits and the FAINS shifts do not collide.
What does the four-hour minimum look like during a discharge window?
The four-hour minimum applies to hourly private duty shifts in the post-hospital arc the same way it applies to every other case. Most discharge windows benefit from shifts longer than four hours, because the transition period has multiple care tasks clustered together. Where the family's need is genuinely shorter than four hours, we refer to a visit-based provider that fits.
How is billing structured when the staffing mix changes over the recovery arc?
Weekly Monday-through-Sunday invoicing at the tier rate that applied to each shift. If the arc moves from skilled nursing to CHHA to companion over the course of the recovery, the invoice line items itemize each shift at the correct tier rate. There is no bundled recovery-arc fee. The family sees what they are paying for at each stage.
What if the recovery does not go as planned and the acuity increases?
The RN Supervisor reassesses. If the acuity crosses into a higher tier, the staffing shifts up (companion to CHHA, CHHA to skilled nursing) at the point of the change. If the acuity requires re-hospitalization or a facility placement, the RN Supervisor coordinates that transition with the family and the physician team. Continuity of the FAINS relationship holds through the transition. Discharging FAINS is never something that happens because the case got hard.