Houston Case Management

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Autumn Leaves communities are specifically designed to deliver the highest quality of caregiving for individuals living with dementia.

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Specializing in Short Term Rehabilitation & Long Term Care Bridging the Gap From Hospital to Home

Whether you are on a FAST TRACK to recovery or need a place you can call home, we have a place for you.

Woodridge Nursing & Rehabilitation Mission Care The Legacy –Assisted & Houston, Texas Houston, Texas Independent Living 713-468-7833 713-643-2628 Bay City, Texas 936-564-1138 Garden Villa Briarwood Nursing El Campo, Texas & Rehabilitation Lexington Place Nursing 979-245-7800 Houston, Texas & Rehabilitation 713-869-5551 Nacogdoches, Texas Matagorda House 936-564-1138 Bay City, Texas Lexington Place 979-245-7800 Nursing & Rehabilitation The Oaks at Beaumont Houston, Texas Beaumont, Texas San Jacinto Manor 713-869-5551 409-842-4550 Deer Park, Texas 281-479-8471 Accepting: Medicare, Medicaid, 2 Private Pay and Insurance All facilities provide Physical, Occupational, and Speech Therapy


CONTENTS

VOL. 3 Issue 3

HOUSTON/GULFCOAST

Every Autumn Leaves community has been designed from the ground up to care for those with dementia. Each building is custom designed to deliver everything your patients’ needs. Levels of Care

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ALZHEIMER’S 5 Programs and assistance designed with those with memory loss; some communities will provide specially trained security measures to prevent residents from wandering.

HOME CARE 11 Allowing a non-medical home care assistant (caregiver) provide transportation, meals, and daily needs. HOME HEALTHCARE 16 Allowing patients to remain at home eliminating travel for treatment; alternative to hospital stay or a skilled nursing facility.

ASSITED LIVING 6 Senior Living community which provides multi-level of senior living options including rehabilitation services, and home healthcare.

HOSPICE 18 In-home or facility end of life care for the terminally ill with pain management, comfort and emotional support being the primary mission for the family and regain independence.

CONTINUUM OF CARE 7 Senior Living community which provides multi-level of senior living options including rehabilitation services, and home healthcare.

SKILLED NURSING & REHAB 20 Licensed and equipped to provide healthcare to meet the needs of more extensive medical issues and to regain mobility, strength, and assist in living after surgery.

facebook/casemgmt © 2014 CMSW

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In the community

CMSA Houston/Gulf Coast 22nd Annual Conference and Expo showcased a red carpet event in providing local case mangers an opportunity to meet and greet local business and organizations, earn CEUs during sessions lead by industry experts, and network with members and professionals. For membership information visit: www.cmsahouston.com Photo: CMSA

Two Great Chapters to Join CMSA Houston/Gulf Coast Chapter & ACMA Greater Houston Chapter Enjoy networking, annual conferences and education!

FOR MORE INFORMATION: www.cmsahouston.com & www.acmaweb.org

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ALZHEIMER’S

Memory Care With a Purpose Making the most of each day is an important part of our focus. With over 15 years of memory care experience, we know that being involved and engaged makes for fulfilling days.

Engagement programs designed specifically to enhance quality of life.

Autumn Leaves of Cinco Ranch 24024 Westheimer Parkway Katy, TX 77494 (281) 392-2050 | License #105776

Autumn Leaves of Meyerland 4710 W. Bellfort Avenue Houston, TX 77035 (713) 360-0000 | License #105181

Autumn Leaves of Clear Lake 14225 Crescent Landing Drive Houston, TX 77062 (281) 938-2800 | License #105048

Autumn Leaves of Pearland 11200 Discovery Bay Drive Pearland, TX 77584 (713) 436-3941 | License #104926

Autumn Leaves of Cy-Fair 17801 West Road Houston, TX 77095 (281) 861-2590 | License #105214

Autumn Leaves of Riverstone 20313 S. University Boulevard Missouri City, TX 77459 (281) 778-2881 | License #104587

Autumn Leaves of Cypresswood 6327 Cypresswood Drive Spring, TX 77379 (281) 374-1750 | License #104657

Autumn Leaves of The Woodlands 10700 Montfair Boulevard The Woodlands, TX 77382 (832) 764-5324 | License #104378

Autumn Leaves of West Houston 1725 Eldridge Parkway Houston, TX 77077 (832) 554-2800 | License #105482

5 CASEMANAGEMENTSOCIALWORK.COM AutumnLeaves.com


ASSISTED LIVING

Let us help your families

With private room and companion rooms in each cottage, Unlimited Care Cottages are non-institutional, non-hotel-like setting, perfect for the elder who prefers a peaceful, family environment. Personalized care is able to be tailored to the individual’s personal daily needs. Call 713-419-2609 or send us an email to let us introduce you to our care setting! We are the best in assisted living cottages, serving residents of Spring, The Woodlands, Conroe, and Kingwood, Texas!

CHECK US OUT!! unlimitedcarecottages.com

facebook.com/unlimitedcarecottages

Providing Cottage Care for over 15 Years!

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Continuum of Care

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Treemont Retirement Community

A comprehensive Senior Community that includes Independent Living, Assisted Living, Skilled Nursing Services is nestled on 9 wooded acres off Westheimer Road. Treemont Retirement Community has provided seniors with a quality lifestyle for 40 years in the Memorial and West Houston area. The Facility’s reputation is synonymous with excellence.

Treemont Retirement Community Amenities Include:

Independent Living Services: Private Luxury Apartments  Beautifully Landscaped Courtyards

Walking Paths  Three Delicious Meals Per Day  Housekeeping Room Service for Meals is Available  Controlled Access Laundry Rooms Available on Premises Personal Laundry Service Available  Library  Gift Shop Recreation/Exercise Room  Scheduled Transportation Assigned Covered and Uncovered Parking All Utilities Paid Except Phone and Cable  Beauty Shop Private Rooms May Be Reserved For Special Occasions and Celebrations

Treemont Health Care Center: Assisted Living Services: ALF #0409

24 Hour Caregiver Assistance  Social and Recreational Events Assistance with Bathing and Dressing Monitoring of Resident Medications  3 Delicious Meals Per Day

Skilled Nursing Services:

Medicare Certified  24 Hour Nursing Services Post Hospital Rehabilitation Care

Personal Care by Senior Allegiance:

Providing Certified & Licensed Home Health and Personal Care throughout the community.

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Call For A Tour Today! 713-783-4100 2501 Westerland Drive, Texas 77063 CASEMANAGEMENTSOCIALWORK .COM 7 Houston, taylorm@treemonthc.com


“They are reliable and make your loved one's needs their first priority. - Elaine, Client

Your patients receive a high level of quality care in your hospital or facility which enables them to recover and to return home. As a medical professional, you take pride in this and want to help ensure that high quality care continues as they transition back to daily life at home. Whether a patient has experienced a heart attack, stroke, surgery, orthopedic injury or are recovering from cancer treatment or other illness, for your patients and their families, there are many new and unexpected challenges as they return home. It can be confusing to understand and coordinate discharge instructions, decipher prescriptions and manage new medications. It may be difficult to schedule and get to follow up appointments with doctors. There may be new mobility issues requiring the use of durable medical equipment like a walker, bedside commode or shower stool. The patient may not have the ability to prepare or may need encouragement to eat a nutritious meal. They may find it difficult to keep up with housework and as a result, do too much when they should be resting. They may try to do things they aren’t ready for, like showering without assistance, which may put them at risk for a fall and another injury. They may even experience depression or anxiety that saps the emotional strength that is so important to a successful recovery. If a patient is also struggling with issues related to dementia or Alzheimer’s, these challenges may be amplified and can be overwhelming.

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At SYNERGY HomeCare, we have the privilege of bonding with cancer patients and their families as they undergo chemotherapy, radiation or other treatment therapies. In addition to physical care giving, we provide clients and families with moral support and encouragement, which is so important while battling cancer. When you consider all of the challenges your patients face, it’s no surprise that one in five Medicare patients ends up back in the hospital within one month of discharge. There are many factors that affect readmissions, including patients’ diagnoses and severity of illness, patients’ behavior, such as adherence to discharge instructions and the availability and quality of post-discharge care.* You’ve taken great care to provide detailed and helpful discharge instructions but what happens after the patient is discharged? Is there a qualified and able family member in place to help see that your instructions are consistently implemented? Unfortunately, this is often not the case. The good news is that SYNERGY HomeCare is an effective partner in helping ensure adherence to discharge instructions and enabling a safer and healthier environment in which to recover. We do this with our proprietary C.A.R.E. team approach. C.A.R.E. stands for Coordinated and Responsive Engagement. This • • • • • • • • • • • • • • •

 Assistance with discharge coordination  Assist with transportation and settling at home  Help ensure discharge instructions are followed  Scheduling of medical appointments  Transportation to/from medical appointments and note-taking  Prescription pick-ups  Medication reminders  Transfer assistance  Assistance with bathing, dressing and personal care  Fall and injury prevention  Meal preparation  Change in condition alerts  Housekeeping/laundry  Errands and shopping  Companionship to help relieve the anxiety and depression that is common following heart attacks, strokes or other serious illness or injury

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3. The health system launched a "Safer Surgery Initiative" to reduce potential adverse surgical events. Advocate initiated a three-year effort on safety in operating rooms, which Ms. Kovich notes is the highest area focused of clinical risk in hospitals.. Areas of focus included effective and correct communication during handoffs from the surgeon's office to the OR scheduler, developing an anesthesia protocol, identifying appropriate and necessary lab tests to be completed prior to surgery and implementing a surgical safeguards checklist. Additionally, Advocate launched an OR team training initiative that focused on "minimizing the hierarchy and power distance in the OR so anybody feels comfortable raising a patient safety concern," Ms. Kovich says. 4. Some of the best results are produced from strategically aligned team work. In addition to aligning leaders across around health outcomes, SYNERGY HomeCare C.A.R.E Teams are the led system by experienced, knowledgeable Advocate puts teams together to collaborate on specific topic areas. "We care managers that work directly with patients and their skilled healthhave care strong teams led by the system to identify best practices and to implement them providers to build a transitional care plan for each unique patient. This care at all sites across the system," Ms. Kovich says. "There isn't something at hospital plan designed different for one purpose only…to achieve a successful patient A andissomething at hospital B."

outcome! For example, in 2010 Advocate was at the 50th percentile for patient falls when compared to the National Database of Nursing Quality Indicators. Within three SYNERGY HomeCare caregivers are available from 2 hours to 24 hours per years, the system reached the 86th percentile by using an aligned team approach day, 7 daysand pershare week.best practices. "For Advocate, this reinforces that consistent to develop focus on best practices and a system approach really makes a difference," Ms. Kovich All are fullysays. trained, insured and background checked for safety and peace of

! mind. Our training even includes memory care strategies to assist in calming 5. Leadership plays a crucial role in achieving a high-reliability culture. anxiety and addressing safety commonhospital for individuals Every morning at 8:30 a.m., the concerns leaders atthat eachare Advocate gather for a coping withhuddle. dementia or huddle Alzheimer’s disease. daily safety In the each leader reports any patient safety events,

near misses or unsafe conditions that occurred in the past 24 hours and predict any specific risks that may arise in the next 24 hours. The risks could include two To learn more, please contact us at 832-266-1704. patients with the same name on the same unit, critical medication shortages, clinical equipment downtime, a staffing shortage or a projected weather alert. "It creates the shared risk or shared situational awareness of what we as leaders are facing today," Ms. Kovich says. "That 15 minutes lets us establish priorities so we can work together to mitigate those risks."

See our ad on page 11

Ms. Kovich adds the daily safety huddles have been "transformational," with leaders verbalizing how the huddles helped them see how their work can directly impact other people. "People have said to me, 'I don't know how we ever did this without the huddle,'" she says.

*Health Policy Brief – HealthAffairs/Robert Wood Johnson Foundation, November 2013

A. Jayanthi

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HOME CARE

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Autumn Leaves’ nine communities in the Houston area all offer unparalleled memory care for those with Alzheimer’s or other forms of dementia With an estimated 340,000 people in Texas currently living with Alzheimer’s, families often look to case managers for help in locating memory care communities offering excellent care. Responding to that need, Autumn Leaves now offers nine locations in the Houston area, all dedicated solely to memory care. All Autumn Leaves communities are staffed by compassionate caregivers who specialize in memory care, with licensed nurses on site seven days a week. In addition, a life engagement program keeps residents active and engaged with artistic expression, physical activity, spiritual support, community connections, and continuing

education. Visitors to an Autumn Leaves community will first notice the community’s open design, wide hallways, and three secured outdoor areas including two beautiful walking paths and a central courtyard. Looking a little closer, however, visitors will notice special touches added specifically to make the environment safe, comfortable and inviting for those with Alzheimer’s or other forms of dementia. For example, in addition to the large, open room near the entrance, there are multiple smaller rooms and sitting rooms located throughout the community. These provide areas for small group activities and privacy for those who want solitude or a place to visit with family members. A soothing color palette and subtle patterns help create a calming atmosphere. Abundant natural light throughout the building helps 13 CASEMANAGEMENTSOCIALWORK.COM


reduce symptoms of “sundowning,” agitation or confusion that affects many people with Alzheimer’s in the late afternoon or evening. Many people with Alzheimer’s or dementia are prone to wandering, a source of constant worry for their families. All Autumn Leaves communities are designed with enclosed outdoor areas, allowing residents to relax outdoors in a safe environment and to enjoy fresh air and sunlight. Similarly, the interior space is fully secured, so that residents have access to the entire community without the risk of wandering outside.

Autumn Leaves locations in the Houston in the area: Autumn Leaves of Cinco Ranch 24024 Westheimer Parkway Katy, Texas 77494 (281) 392-2050 Autumn Leaves of Clear Lake 14225 Crescent Landing Dr. Houston, Texas 77062 (281) 938-2800 Autumn Leaves of Cy-Fair 17801 West Rd. Houston, Texas 77095 (281) 861-2590 Autumn Leaves of Cypresswood 6327 Cypresswood Drive Spring, Texas 77379 (281) 374-1750

Autumn Leaves of Cinco Ranch, the newest property in the Houston area, features the stateof-the-art Vigil System, a motion sensor program in each resident’s private room that allows for safer independent living. The system subtly alerts staff members, if needed, and gathers information that serves to improve the resident’s comfort level.

Autumn Leaves of Meyerland 4710 W. Bellfort Ave. Houston, Texas 77035 (713) 360-0000

Residents have the choice of private or companion apartment floor plans, and may bring their own furniture, if desired, when moving into a community. In all of the communities, each bedroom and bathroom is equipped with an Emergency Call Response System.

Autumn Leaves of The Woodlands 10700 Montfair Blvd. The Woodlands, Texas 77382 (832) 764-5624

Autumn Leaves of Pearland 11200 Discovery Bay Drive Pearland, Texas 77584 (713) 436-3941 Autumn Leaves of Riverstone 20313 S. University Blvd. Missouri City, Texas 77459 (281) 778-2881

Autumn Leaves of West Houston 1725 Eldridge Parkway Houston, Texas 77077 (832) 554-2800 14


Housekeeping, laundry and linen services are included at Autumn Leaves, as is assistance with daily activities including dressing, bathing, hygiene, and mobility. A full-service beauty and barber salon are also located on the premises.

At every Autumn Leaves community, residents’ families are actively involved in designing individualized care plans for their loved ones. The communities also offer free educational programs to the public. Day stay and respite care is also available.

Many people with Alzheimer’s or dementia experience declining appetite. Autumn Leaves communities are designed to encourage healthy eating. Each community features two dining areas, where residents enjoy three homemade, nutritious meals daily, all freshly prepared by Autumn Leaves’ culinary staff. In addition, nutritious snacks are offered throughout the day. A spacious private dining area also allows residents and their families to host family get-togethers.

For additional information and to schedule a tour of the Autumn Leaves in your area, call (888) 662-8886.

See our ad on page 5

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At BrightStar Care®, our goal is to improve the quality of life of those entrusted to our care. We are here to make more possible everyday and help you get the most out of life. > Companion and personal care services > One hour to 24-hour care > Bathing, dressing, personal care > Medication management > Post-op, rehabilitation, hospital sitter care > Meal prep, errands, transportation > All care and staff overseen by a Registered Nurse

ServingAustin, Houston and Surrounding Areas Serving Round Rock, Georgetown & Surrounding Areas BrightStar of North Houston BrightStar of The Woodlands 281-367-7827

Friendswood 512 452 9800 281-606-4335

7703 N. Lamar Blvd., Austin, TX 78752 BrightStar of Sugar LandSuite 418, BrightStar of Bellaire 2508 Williams Dr, Ste 255 Georgetown, TX 78628 W. Houston/Katy SW Houston 281-201-3700 Locally Owned and Operated by Chad 832-730-1255 & Rhone McCall

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HOME HEALTHCARE

Prevent hospital readmissions ResCare HomeCare is your solution Skilled Nursing Complex Medical Care Physical, Occupational & Speech Therapies Discharge your patients smoothly. Get them on a path to a speedy recovery while at home — where we all want to be.

281.428.2244 ResCareHomeCare.com

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HOSPICE Â

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Caring for Moments That Matter AseraCareÂŽ provides compassionate end-of-life care when it’s needed most. With more than a decade in service, our caring team of professionals provides hospice services that meet the physical, social and spiritual needs of each patient. Our services include: UĂŠĂŠ->“iĂŠ`>ÞÊ>`Â“ÂˆĂƒĂƒÂˆÂœÂ˜Ăƒ UĂŠĂŠ ĂŒÂ‡Â…ÂœÂ“iĂŠĂ›iÂ˜ĂŒĂŠV>Ă€i UĂŠĂŠ-ÂŤiVˆ>Â?ĂŠĂƒiĂ€Ă›ÂˆViĂƒĂŠvÂœĂ€ĂŠĂ›iĂŒiĂ€>Â˜Ăƒ UĂŠĂŠ iĂ€i>Ă›i“iÂ˜ĂŒĂŠĂƒiĂ€Ă›ÂˆViĂƒ If you or your loved one would benefit from holistic support provided by a caring team of professionals, contact us today.

AseraCare - Houston 1235 North Loop West, Suite 215 Houston, TX 77008 713-864-2626 www.AseraCare.com This agency welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, gender, sexual orientation, source of payment, or ĂŒÂ…iÂˆĂ€ĂŠ>LˆÂ?ÂˆĂŒĂžĂŠĂŒÂœĂŠÂŤ>Ăž°ĂŠ -‡££äxLJ£ÎÊ £äx

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HOSPICE

Beaumont

409-­832-­6700

Houston

Houston North

281-­277-­1151 210-­520-­7734

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SKILLED NURSING & REHAB !

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baywood crossing rehabilitation & healthcare center

The$Next$Step$to$Recovery$

Our Transitional Care Unit specializes in providing the newest technologies for those requiring rehabilitation. Offering physical, occupational, and speech therapy, our rehabilitation team has the expertise needed to design a specific therapy program based on each patient’s needs. Our spacious gym allows each patient to utilize every aspect of our therapy program to their fullest capability. We specialize in a range of diagnoses to include orthopedic and stroke recovery as well as offering services to medically complex patients. This can include IV therapy, wound care, and much more. 5020 Space Center Blvd Pasadena, Texas 77505 (713) 575-1800 www.baywoodcrossingrhc.com OUR FRIENDLY AND PROFESSIONAL IN-TAKE ! COORDINATORS ARE READY TO ASSIST YOUR PATIENTS, AND THEIR LOVED ONES. CALL TODAY

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SKILLED NURSING & REHAB

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SKILLED NURSING & REHAB

A name you can trust for rehabilitation and health care.

Post-Surgical, Short-Term Rehab Heartland - Austin Heartland - Bedford ManorCare - Dallas Heartland - Fort Worth Heartland - North Richland Hills Heartland - San Antonio Heartland - San Antonio North ManorCare - Sharpview ManorCare - Webster ManorCare - West Houston ManorCare - Willowbrook

800.736.4427 www.hcr-manorcare.com

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