transition care management
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SkilledNursingTransitionalCare (714) 921-9200
www.SeniorHomeAdvocates.com
We provide ongoing care coordination,transitional care management andconcierge placement servicescombined with specialized senior realestate services.
By helping families and maturing adultsnavigate the aging process our goal isto alleviate the anxiety associated withthe aging process and our currentfragmented healthcare system.
We Are Your Senior Care Coordinators.
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 ContactSenior Home Advocates At (714) 921-9200
Summary have strong financialincentives to prevent ,Monitoring resident post-discharge care has becomea priority in our new "value driven" healthcare system
Attend initial IDT meeting
Review medication listprior to hospitalization
Bedside Visit to reviewfamily & patient goals
Contact PCP
Schedule 7 day f/u visitwith doctor
Coordinate transportation
Community Referrals
Assist family implementthe discharge plan
Reassurance calls doneweekly
24./7 HealthcareAssistant
Pre‐Discharge
At Time of Discharge
Post Discharge
offers post dischargecoordination and discharge plan via“live in person advocates” to assist seniors and families
navigate the 30 days post discharge
Skilled Nursing Homeshospital readmissions
Senior Home Advocatesimplementation
ResultsDecreased readmissionsDecreased MortalityIncreased physician follow-upIncreased understandingDecreased client/caregiver stress
(714) 921-9200 www.SeniorHomeAdvocates.com
Benefits
Increase of Care Value 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 reconciliationand treatment adherence Know what other doctors are prescribing Keeping patients on track with medication
Increased family and patient engagement Patient centered care planPatient friendly software to help with medication remindersImproved communication between family andproviders Decreased duplicative diagnostic testing 24/7 Access to Nurse Help Line
Nursing Facility For TheDoctors
For TheResident
Senior Home Advocates bridges the gap of Transitional Care Management. Our trained Advocateswill work as your TCM coordinators with the goal of increasing
quality care and preventing readmissions.
Pre Discharge
Post Discharge
Conduct familyinterview
within 48 hoursof admission
Contact &update primarycare physician
Collaboratewith IDT during
resident stay
Prepare resident,family to be
active in DCplanning
“TransitionalAdvocate” to
improve patientsatisfaction
Arrangefollow-up
Contact family24 hours post72 hours post
Weekly - 30 days
Coordinatefirst dr. visit
7 to 14 days’post discharge
Sync recordsfor Physician
and family
Create patientcentric care
plan at time ofdischarge
Contact HomeHealth monitor
dischargeimplementation
Support family &
on going case
management
Provide facilitywith summary
of care timeline per patient
Process
1 2 3567
1
56 8
Attendinitial care
plan meeting if possible
Obtain consentand universal
HIPPA release
2
4
5 6
2 3
4 6Medication
reconciliation andmedication
adherence monitoring
We Maintain Compliance For You.A patient-centered solution that combines industry- leading technology and 24/7care coordination services. Senior Home Advocates provides turnkey Transitional
Care Management & Chronic Care Management services, allowing practices of anysize to easily meet the challenging requirements for CPT code 99490, 99495, 99496
Promote wellness and increased resident satisfaction post discharge by monitoringand implementing the facility “discharge plan/transition strategy” for a minimum of90 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’ postdischarge
Expected Outcomes.