Overview & Description

Senior Support Advisors has taken industry indicators over past years and identified areas in which a proactive approach to the increasing readmissions is exercised.

In securing and understanding these trends, Senior Support Advisors has allocated an individual division specifically to act and operate as a “central agency” for the collection, classification and distribution of qualified home care referrals.

The program focuses on ensuring the appropriate referrals are made to the HHA’s based on the diagnoses of the client and the ability, scope and experience of the HHA to adequately meet the specific need.

Senior Support Advisors Discharge Management Program provides oversight and evaluation of the HHA’s policies and practices whereby commanding the referrals to qualified Healthcare professionals or to those individuals who require the services of a caregiver and social support service.

Our Mission

The program adopts the theory of bridging the gap during patient transition, that will ultimately avoid therapeutic errors, failed hand-offs, absent or delayed follow-ups and reduce discharges against medical advice (AMA).

The vision and obligation as an healthcare professional remains to reduce facility discharges with a model which monitors the signs and symptoms of the post discharge diagnoses.

Senior Support Advisors shall utilize only qualified Healthcare professionals within its Network of Providers to further enhance the continuum of care, formulating an internal ACO (Accountability Care Organization) model to serve the ailing patient.

Point & Scoring System

Senior Support Advisors Discharge Management Program shall adopt methods to analyze the outcomes of the program implementing Quality Indicator tools/charts for a complete assessment, validation and continued utilization of the HHA.

The “3 Point Quality System” focuses on the HHA internal processes and current trends and will include specific areas including:

Admissions & Discharges

Clinical Practices & Reporting

Customer Satisfaction & Quality Assurance

The “3 Point Disease System” specifically focuses on the methods used by HHA’s to meet and deliver appropriate care relating to these client’s specific diagnosis including:

Patient, Family or Caregiver Training & Education

Communication, Monitoring & Follow-up

Diagnosis benchmarks and Response

Our Services

The Discharge Management Services has provided key components and opportunities for its’ healthcare partners to ensure validation and completeness of the Continuum of Care. Our services include:

Transitional Care Coordination

(Monitoring post diagnoses)

Care Transition Interventions

(including Home Visits, Medication, Self-Management & Reconciliations)

Identifying Signs & Symptoms

Follow-up to Physician Appointments

Patient & Family Diagnosis Specific Education

Interactive communication and follow-ups

HHA Quality screening and assessment

Benefits

For the facilities and healthcare partners, our “free” program will provide an alternative means to enhance the marketing and public relation efforts and as an extension to their current practices, delivering value as well as an avenue to ultimately reducing re-admissions.

Senior Support Advisors, in essence, becomes a complete oversight/eyes and ears to the facility for all home care referrals.

For our client, the program provides an assurance of a structured transition plan, providing an independent monitoring and support theory. Each client and/or family member(s) will be provided with continual communication and in-home visits intermittently and as needed throughout the 30 day period.

Again, communication remains a high priority and therefore periodic reports will also be provided to the healthcare team to ensure all members of the continuum are well informed.