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At Senior Home Care, we partner with physicians, case managers, hospitalists and other providers to deliver innovative and seamless patient care.
As an integral part of each patient’s health care team, our clinicians understand the concerns of referring physicians and the demands on their time. Many of our dedicated clinicians have spent many years working in hospitals and acute care facilities prior to joining Senior Home Care. They know how to help while serving as "eyes and ears" for physicians after patients are discharged from the hospital.
When a physician refers a patient to us for home health care, our planning begins while the patient is in the hospital. Our Patient Care Coordinator meets with the patient and family members before discharge to review the “Discharge Preparation Checklist,” provide the patient a VIP card with our contact information and explain the purpose/use of the “Personal Health Record.” Our ultimate goal is to smooth the patient's transition back home and work toward strong long-term outcomes.
Senior Home Care's Transitional Care Model standardizes our process for high-risk patient care using four pillars: (1) medication self-management, (2) follow up with PCP/Specialist, (3) use of Personal Health Record and (4) knowledge of red flags/warning signs/symptoms and how to respond.
Patients Must Qualify for Transitional Care
Those who qualify for the Transitional Care Program, after the referral is received, must be 65 or older with traditional Medicare and a recent hospitalization (non psychiatric). They must have a primary diagnosis of at least one of the following: Heart Failure, Acute Mycocardial Infarction (AMI), Coronary Artery Disease, Cardiac Arrhythmia, COPD, CVA or Pneumonia.