Each senior living community has successfully completed a screening and assessment process and has commited to provide person-centered, accountable care.
Registered Nurse and Social Work care managers use Motivational Interviewing techniques and Person-Centered Planning to engage the client and family to complete a Transitional Care Assessment and develop a client-centric Plan of Care. For continuity of care, and with the client’s consent, the Plan of Care is shared with the senior housing community to which the patient transitions.
1. Transitional Care Assessment
- Registered Nurse and/or Social Work care managers complete an assessment that identifies housing and transition of care needs.
2. Client-Centric Care Plan
- Care managers use Person-Centered Planning and Motivational Interviewing skills to engage the client to discuss self-management goals and develop a plan of care.
3. Senior Housing Referral
- Care managers recommend appropriate senior housing communities based on the Transitional Care Assessment, client preferences and the client’s financial resources. Client's care needs are matched with the Senior Living Communities' strengths.
4. Tours Assistance
- Assistance is provided with scheduling tours, reviewing the Tour Checklist and debriefing with the client after each completed tour.
5. Care Coordination
- Care managers review discharge instructions, provide medication reconciliation, schedule initial physician visit and transportation, and provide chronic disease self-management teaching (iTransitions program).
6. Post-Transition Care Management
- Care managers provide follow-up phone calls and/or visits for up to thirty days post transition.