We provide ongoing care 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.
2. We provide ongoing care 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
3. Summary
have strong financial
incentives to 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
4. 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 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
5. Senior Home Advocates bridges 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
6. We Maintain Compliance For 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.