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Post-Acute Services & Transitional Care Management

High Care shall provide highly coordinated care for members transitioning from an acute setting and managing chronic diseases. Services will be rendered in the members’ home or appropriate care setting. High Care’s interdisciplinary care team will focus on disease management and education by proactively addressing the member’s medical and social needs across the illness trajectory. Transitional Care Management (TCM) aims to decrease hospital and emergency department utilization, improve clinical outcomes, and reduce gaps in care.
Doctor's Appointment

Scope of Care

Initial outreach to member with 24hrs of receipt of referral. Member will be scheduled 
for in-home visit with Nurse Practitioner or Medical Director. Member will receive complete head-to-toe assessment and placed on the appropriate level of care for Transitional Care Management services.

Senior end-of-life care Palm Springs
Hospice care in Riverside CA

Service Description

Initial Assessment

  • Completed by a Nurse Practitioner or Medical Doctor

  • Assessed in home or appropriate care setting.

  • Perform Medication Reconciliation

  • Assess for environmental safety.

  • Assess for Re-admission risk.

  • PHQ-2 Depression Screening

  • Assess for substance abuse.

  • Educate members on disease progression and management.

  • Develop individualized Plan of Care

  • Determine appropriate level of care while on-service.

  • Assist in coordination of care with providers.

  • Discuss goals of care, Advanced Care Planning, and POLST

 In-home Nursing visits and interventions

  • Check and document vital signs.

  • Provide disease specific nursing interventions.

  • Document progress toward Plan of Care goals

  • Educate members in disease management. 

  • Educate members in medication adherence.

  • Coordinate with PCP or Palliative provider for labs, imaging, treatments, or medication changes.

  • Goals of Care, Advanced Care Planning

Transitional Care Management

  • Coordinate transitional care from acute to community setting. 

  • Coordinate referrals to appropriate medical, behavioral, social, and community resources. 

  • Assess need for durable medical equipment and coordinate referral, ordering and delivery. 

  • Work with dual diagnosis and/or homeless populations to develop specialized plan of care.

  • Assessment of health literacy level.

  • Assist with coordination of transportation to and from medical appointments.

Complex Care Management

  • Individualized, disease specific education provided to members and caregivers on admission and reinforced weekly by care management team.

  • Extensive education provided on how to manage stresses, frustration, fatigue, pain, and isolation associated with chronic diseases. 

  • Extensive education on disease management and progression.

  • Coordination with PCPs, specialists, and other appropriate providers

  • Reinforce medication adherence.

  • Collaboration with Interdisciplinary Care Team, PCPs, specialists, and medical group

  • Discuss goals of care, Advanced Care Planning, and coordination of hospice evaluation when appropriate

Psychosocial Services

  • Psychosocial assessment completed by Social Worker trained in complex care management.

  • Assessment to be completed within two (2) weeks of admission.

  • Coordination of behavioral health services including substance abuse treatment, cognitive behavioral therapy, grief counseling, etc.

  • Connect members with appropriate behavioral and social resources within the community.

  • PHQ-9 Depression Screening

  • Assess for environmental safety.

  • Assistance with caregiver support services

  • Assistance with IHSS and other financial support applications

  • Access to in-home and telephonic Social Work visits after assessment as needed.

  • Provide any follow-up on identified needs.

  • Discuss goals of care and Advanced Care Planning

  • Hospice education upon request or when appropriate

24/7 Access

  • Access to Complex Care Provider team

  • Access to Nurse triage line

  • Access to Nurse Visits

  • Access to Social Work Visits

  • Access to labs, imaging, treatments, and medication

  • STAT delivery of prescription medications related to change of condition.

Get in Touch

Contact us by phone to see if you or your loved one qualifies for one of our programs.

Hospice care near Coachella Valley
(951) 389-8067

© 2024 by High Care Hospice Inc. All rights reserved.

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