Transitional Care Management
An alarming rate of one in five Medicare beneficiaries are rehospitalized within 30 days of being discharged from a hospital. The rate nearly doubles among those with high-risk medical, functional and cognitive conditions.
SeniorBridge safely transitions high-risk patients from the hospital or other facility to home and prevents unnecessary rehospitalizations by providing a specially trained team of licensed nurse practitioners, nurse and social worker geriatric care managers who coordinate care in the home.
Our Transitional Care Management Model consistently delivers improved patient outcomes and reduced cost of care among high-risk patients.
Click to enlarge
Services Provided by Specially Trained Nurses and Social Workers
- Visiting patient prior to discharge from the hospital and multiple times in the home
- Assessing medical, functional and environmental needs
- Developing and implementing individualized transition care plan in patient’s home
Care Coordination to Maintain Health and Function
- Setting up follow-up doctor appointments and accompanying when appropriate
- Medication reconciliation
- Seamless collaboration with health professionals and health plan case managers