We at Pathways to Care are here to help guide families facing the difficult choices associated with the care and needs of their aging loved ones. We provide a safe pathway across all levels of care by having expertise in the following areas...

1. ONLINE
LANGUAGE
COURSES
PATIENT
AL
F
HHA
We at Pathways to Care are here to help guide
families facing the difficult choices associated
with the care and needs of their aging loved
ones. We provide a safe pathway across all
levels of care by having expertise in the
following areas...
TRANSITIONAL CARE MANAGEMENT
CARE SUPPLIES
LONG TERM CARE CASE MANAGEMENT
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT
& LONG TERM CASE MANAGEMENT | GUIDENCE IN LOCATING CAREGIVERS & CARE
FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE SERVICES FOR
SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

2. What is Transitional Care Management
Care coordination and counseling
services to support the transition from
an inpatient hospital setting (including
acute hospital, rehabilitation hospital,
long-term acute care hospital), partial
hospital, observation status in a
hospital, or skilled nursing facility
(SNF), to the patient’s community
setting (home, domiciliary, rest home,
or assisted living) in order to prevent
re-admissions.
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

3. There Are Two Distinctly Different Types of Acute Hospital
Discharge Situations...Both of Which Hold Opportunities For
Decreasing Hospital Re-admission Rates
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Discharge from the acute hospital to a skilled
nursing facility. Requires safeguarding against a
pre-mature discharge from the hospital and better
patient care while in the skilled nursing facility.
(Kaiser Case Study Example.)
•
Discharge from the acute hospital or skilled nursing
facility to the home. Requires safeguarding against
a pre-mature discharge from the hospital and
patient follow-up and 30 day tracking by the
primary physician.
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

4. How Serious is the Readmissions
Problem?
According to the federal government, one in five elderly
patients winds up back in the hospital within 30 days of
leaving.
The readmission of Medicare patients alone costs $26
billion annually, $17 billion of which is spent on return
trips that wouldn’t need to happen if patients received
proper care during their first visit and/or had an
adequate post discharge follow up.
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

5. ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

6. To Fix The Problem, Medicare is Now Taking Action...
•
Penalizing hospitals if the patient returns
within 30 days
•
in 2015 Medicare will penalize the skilled
nursing facilities for patients that readmit to
the hospital within 30 days of being
discharged from the skilled nursing facility.
•
Providing extra Medicare billing revenues
for primary physicians who are willing to
follow up and track the patient throughout
the first 30 days to ensue that they are
adhering to the discharge instructions.
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

7. Medicare is Compensating Primary Physicians To Help Lower
Readmissions. The Primary Physician is Well Equipped To
Ensure Adherence To The Discharge Plan Except For When There
is a Néed To Establish a Long Term Care Arrangement
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Coordination to ensure immediate follow up by the primary physician in order
to determine that the patient is adhering to the discharge instructions and that
there are no signs or symptoms of possible complications.
Pathways to Care brings Transitional Care Mangement Steps Beyond The
Expertise of the Primary Physician
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Guidance for the family in choosing the right care arrangement.
Counseling to get the patient to agree to a safe care arrangement.
Family conflict resolution
Solutions on how to pay for the care
Med-Cal and VA benefits assistance
Solutions on what to do with the house
ONLINE
LANGUAGE
COURSES

8. ONLINE
LANGUAGE
COURSES

9. ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

10. Transitional Care Management Day-by-Day Overview
Prior to or on day of discharge, we contact the patient & the family
• Introduce our transitional care management
services
• Set telephone appointment for 2nd day Nurse
Practitioner /Case Manager call
• Obtain discharge instructions
• Offer family use of our on-line patient
management software
• Assess family concerns, plans and support
commitment
• Answer any questions the family may have
• Invite the family to use our team as a resource
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

11. Transitional Care Management Day-by-Day Overview
•
MD or NP to follow up at home day after discharge or
2 Days after discharge a nurse will contact the patient to
ensure they understand and are adhering to the discharge
plan
Educate and explain any difficult to understand D.C.
instructions
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Identify signs and symptoms of possible complications in
order to provide early intervention instructions
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Ensure receiving home health care and/or non- medical
home care visits are in place
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Patient has received recommended DME and supplies
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Patient has scheduled recommended doctor follow-up visits
and has arranged transportation.
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Perform medication review and education
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

12. Transitional Care Management Day-by-Day Overview
Reassurance calls on 2nd, 3rd and 4th week after
discharge and then quarterly as needed
• Review for continued adherence to the
discharge plans
• Ensure doctor and or specialist appointments
have been made and transportation is
arranged
• Identify signs and symptoms for early
intervention
• Offer family counseling to assist with planning
and preparing for the event that the patient
needs long term care
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

13. Coordinating Care Across The Spectrum
Transitional Care Management isn't intended to replace any type of health care provider.
Our strategy is to ensure effective planning and communication between the family,
doctors, hospitals, skilled nursing facilities, home health care agencies, social workers,
in- home caregivers, assisted living facilities, RCFE's and other health care participants.
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

14. Transitional Care Management Day-by-Day Overview
Our strategy is to ensure effective communication between the family, doctors,
hospitals, skilled nursing facilities, home health care agencies, social workers,
and other health care providers.
•
Calls made by the nurse practitioner and health care coach
are relayed to the patient’s primary physician
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Web based patient management software through which
families, doctors and SPN can communicate and keep a log
of the patient's status
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This software allows us to track and assign responsibility
for carrying out each transitional care step
•
As it is web based, all the relevant parties can easily see
which steps have been completed and access important
documents such as health insurance information, discharge
instructions, medication lists and doctor contact
information, power of attorney and trust documents.
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

15. Transitional Care Management When Long Term Care is Needed
Enlist the support and cooperation of the family in overseeing the
patient’s care and planning for the future
•Help for the family in choosing the
right care arrangement whether its inhome care, board & care (RCFE),
assisted living, or skilled nursing care.
Education on the care options
available in your area, how much they
cost and which type is appropriate
given the patient's care needs
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

16. Transitional Care Management When Long Term Care is Needed
Families often times face significant hurdles to succeeding at
getting adequate care arrangements established.
•Guidance and assistance in getting the patient to agree to
a safe care arrangement. We have a clinical social worker
on staff with many years of experience working with
dementia and Alzheimer's patients. We have developed
techniques for both higher and lower levels of cognitive
impairment to bring the patient to make the right choice for
a safe living and care arrangement.
•Family conflict resolution: the counseling we provide in
helping the family choose a care arrangement and to find a
solution on how to pay for care naturally facilitates and
resolves the reasons for most of the conflicts that families
are facing during this stressful time.
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

17. Transitional Care Management When Long Term Care is Needed
Families are Looking for Solutions on how to pay for care
• Personal counseling with financial tools designed to
help the family compare each care scenario side-byside and make the best choice for their loved one.
Patient's income, expenses, available assets, and
government benefit eligibility is considered for each
potential care arrangement such as home care,
board & care, assisted living, or custodial skilled
nursing facility care
• This tool is the basis for breaking-through difficult
discussions between family member and the patient
.
ONLINE
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COURSES

18. Transitional Care Management When Long Term Care is Needed
Show families how to qualify for government financial benefits and
assist with applications
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Families need personal help to apply and receive financial
benefits such as long term Medi-Cal, non-nursing home
Medi-Cal, VA Aid & Attendance pension, and VA in-home
care
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Some families fail to go after these critical benefits as they
think they won't qualify because they have too much in
income or assets. They need guidance from a
knowledgeable resource that can dispel the myths and
demonstrate the legal and ethical options for obtaining
eligibility and how it can help make their care choices
possible
•
Families need assistance with long term care insurance
claim forms to help the family decide when is the appropriate
time to submit a claim
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

19. lowering hospital readmissions…how we can help
We make locating quality care providers easy
We provide education on the long term care options that are available
in the county and help the family to determine which are appropriate
given the patient’s level of care.
We help the family locate quality care providers whether it’s in-home
caregivers, home health care, hospice, assisted living, board & cares,
and long term custodial skilled nursing facilities.
Some patients may have particular care needs or issues which make
facility placement difficult. Not a problem, this is our expertise. We
have a strong track record of matching challenging care situations with
a welcoming provider.
Note that we also assist the family in negotiating the contracts and
advocating on the client’s behalf when disputes arise.
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

20. lowering hospital readmissions…how we can help
Our greatest resource are our people. We have a highly trained
staff with a wide variety of expertise that can make the
difference in coming up with a successful plan of action.
Among our staff we have
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RN’s
NP’s
PA’s,
LVN’s
LCSW
CPA
An attorney
• Medicare and Medi-Cal health
insurance experts
• Real estate and mortgage
experts
• Financial investment and
management experts
• Placement Specialists
Throughout Southern California, this group works together as a team
and can meet with the family in our offices, in the care facility, or in their
home.
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

21. In closing
Working as a team we can help
Grow both of our organizations
We need to go further in recognizing that
care coordination is a collaborative
process supported by a multidisciplinary
team and expand the support and
delivery of services to the multiple
clinicians who provide those services
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

22. Thank you
resources
National Transitions of Care Coalition (NTOCC) www.ntocc.org
Centers for Medicare & Medicaid Services (CMS) www.cms.gov
www.cms.gov/Medicare/Medicare-Fee-for-Service.../FAQ-TCMS.pdf
Care Coordination and Registered Nurses’ Essential Role, Position Statement of the American Nurses
Association. www.nursingworld.org/position/care‐coordination.aspx.
CMS Approves New Codes & Reimbursement for Transitional Care & Chronic Care
Coordination.www.capitolupdate.org/index.php/2013/01/cms‐approvesnew‐codes‐reimbursement‐for‐
transitional‐care‐chroniccare‐ coordination/. 2013 CPT® Codebook. American Medical
For information on how to start a extensivist program, go to:
http://www.innovations.ahrq.gov/content.aspx?id=2903
Senior Places Network www.SeniorPlacesNetwork.com
ONLINE
LANGUAGE
COURSES
TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT
| GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE
SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |

23. Contact us
For more information or a free consultation
John Menzies
Clark MBA,CPA
Expert advisor on
creating solutions on
how to pay for the cost
of senior care. With an
expansive knowledge
of long term care
insurance, MediCal, VA
Benefits and the aging
process.
ONLINE
LANGUAGE
COURSES
Visit us at
www.Pathwasy2Care.com
or call
714 408 4413
Elena Merchand,
LVN,WCC, DWC
Expert in finding local
senior care facilities in
Orange County with
over 25 years of
experience in the
medical industry as a
nurse, wound care and
diabetic specialist and
licensed administrator.