Transition Care Management

Transition Care Management

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  Skilled Nursing Transitional Care (714) 921-9200 www.SeniorHomeAdvocates.com
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  We provide ongoingcare coordination, transitional care management and concierge placement services combined with specialized senior real estate services. By helping families and maturing adults navigate the aging process our goal is to alleviate the anxiety associated with the aging process and our current fragmented healthcare system. WeAreYourSeniorCareCoordinators. When considering the options for senior care we take a comprehensive view, From the clinical health concerns to the financial aspects of care we are here to be of assistance. We understand that most families only deal with an aging parent once or twice in a lifetime, and often are not aware of the questions to ask. As a team we work with families everyday and have acquired an arsenal of techniques and strategies to help manage the aging process with dignity. If You Have Question Please Contact Senior Home Advocates At (714) 921-9200
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  Summary have strong financial incentivesto prevent , Monitoring resident post-discharge care has become a priority in our new "value driven" healthcare system Attend initial IDT meeting Review medication list prior to hospitalization Bedside Visit to review family & patient goals Contact PCP Schedule 7 day f/u visit with doctor Coordinate transportation Community Referrals Assist family implement the discharge plan Reassurance calls done weekly 24./7 Healthcare Assistant Pre‐Discharge At Time of Discharge Post Discharge offers post discharge coordination and discharge plan via “live in person advocates” to assist seniors and families navigate the 30 days post discharge Skilled Nursing Homes hospital readmissions Senior Home Advocates implementation Results Decreased readmissions Decreased Mortality Increased physician follow-up Increased understanding Decreased client/caregiver stress (714) 921-9200 www.SeniorHomeAdvocates.com
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  Benefits Increase of CareValue to resident and family CareSync platform as a tool for care coordination Prevent readmissions Track patients post-discharge Provide hospital/SNF with real time tracking of discharged patients Provide a “marketable” TCM program to referral source Ability to bill TCM and transition to CCM Access to critical information Communication with other physicians Avoid duplicate tests Medication reconciliation and treatment adherence Know what other doctors are prescribing Keeping patients on track with medication Increased family and patient engagement Patient centered care plan Patient friendly software to help with medication reminders Improved communication between family and providers Decreased duplicative diagnostic testing 24/7 Access to Nurse Help Line Nursing Facility For The Doctors For The Resident
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  Senior Home Advocatesbridges the gap of Transitional Care Management. Our trained Advocates will work as your TCM coordinators with the goal of increasing quality care and preventing readmissions. Pre Discharge Post Discharge Conduct family interview within 48 hours of admission Contact & update primary care physician Collaborate with IDT during resident stay Prepare resident, family to be active in DC planning “Transitional Advocate” to improve patient satisfaction Arrange follow-up Contact family 24 hours post 72 hours post Weekly - 30 days Coordinate first dr. visit 7 to 14 days’ post discharge Sync records for Physician and family Create patient centric care plan at time of discharge Contact Home Health monitor discharge implementation Support family & on going case management Provide facility with summary of care timeline per patient Process 1 2 3567 1 56 8 Attend initial care plan meeting if possible Obtain consent and universal HIPPA release 2 4 5 6 2 3 4 6 Medication reconciliation and medication adherence monitoring
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  We Maintain ComplianceFor You. A patient-centered solution that combines industry- leading technology and 24/7 care coordination services. Senior Home Advocates provides turnkey Transitional Care Management & Chronic Care Management services, allowing practices of any size to easily meet the challenging requirements for CPT code 99490, 99495, 99496 Promote wellness and increased resident satisfaction post discharge by monitoring and implementing the facility “discharge plan/transition strategy” for a minimum of 90 days Create interoperability amongst “circle of care” post discharge to include physicians, home health providers, non medical care providers, pharmacy and family Prevent avoidable readmission and reduce unintended healthcare outcomes Create safe and sustainable transitions - prevent transitions failure Measure meaningful data and report resident outcomes/satisfaction 90 days’ post discharge Expected Outcomes.