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Guide to Senior Care Options & Patient Care Assisted / Alzheimer’s – Home Healthcare – Hospice – Home Care Senior Living - Skilled Nursing & Rehabilitation – Rehabilitation Hospital MOBILE AND DIGITAL AVALIABLE
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CASEMANAGEMENTSOCIALWORK.COM
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CONTENTS
COVER
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SYNERGY HomeCare has proven to be instrumental in helping our referral partners achieve better patient outcomes. FEATURE PATIENT CARE
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ACC Patient Navigator Program to address these issues through a personalized approach focused on meeting the needs of heart disease patients before and after they leave the hospital.
DINNER MEETING - PRESENTATIONS Join CMSA Houston/Gulf Coast Chapter AMCA Greater Houston Chapter Join networking, annual conferences, education/CEUs FOR MORE INFORMATION: www.cmsahouston.com Non-Member Case Managers please note there is a special rate for you to attend in 2014! -AND-
www.acmaweb.org
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DEPARTMENTS
CONTINUUM OF CARE 7 Senior Living community which provides multilevel of senior living options including rehabilitation services, and home healthcare.
Volume 3 Issue 2 HOUSTON/GULFCOAST
Logon to our website for additional information on
HOME CARE 8 Allowing a non-medical home care assistant (caregiver) provide transportation, meals, and daily needs.
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HOME HEALTHCARE 13 Allowing patients to remain at home eliminating travel for treatment; alternative to hospital stay or a skilled nursing facility.
Senior Companies Newsletters Upcoming events
HOSPICE 15 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. SKILLED NURSING & REHAB 18 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.
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PRIVATE DUTY NURSING 18 Providing 1-on1 nursing care in the home from register nurses (RNs) or licensed practical nurses (LPN). REHABILITATION HOSPITAL 25 Inpatient rehabilitation hospitals devoted to the rehabilitation of patients with various neurological and orthopedic, and other medical condition to regain strength and stabilization.
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Copyright © Case Management-Social Work LLC, all rights reserved. No part of this guide may be reproduced or transmitted in any form or by any means without written permission from Case Management-Social Work LLC. Printed in the USA.
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PATIENT CARE
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ELIMINATE HARM ACROSS THE BOARD Days Since Last Readmission READMISSIONS PREVENTION:
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Conduct enhanced admission assessment of discharge needs and begin discharge planning at admission
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Conduct formal risk of readmission assessment; align interventions to patient’s needs and risk stratification level
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Perform accurate medication reconciliation at admission, at any change in level of care and at discharge
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Provide patient education that is culturally sensitive, incorporates health literacy concepts and includes information on diagnosis and symptom management, medications and post-discharge care needs
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Identify primary caregiver, if not the patient, and include him/her in education and discharge planning
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Use teach-back to validate patient and caregiver’s understanding
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Collaborate with post-acute care and community-based providers including skilled nursing facilities, rehabilitation facilities, long-term acute care hospitals, home care agencies, palliative care teams, hospice, medical homes, and pharmacists
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Before discharge, schedule follow-up medical appointments and post-discharge tests/labs; for patients without a primary care physician, work with health plans, Medicaid agencies and other safety-net programs to identify and link patient to a PCP
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Conduct post-discharge follow-up calls within 48 hours of discharge; reinforce components of after-hospital care plan using teach-back and identify any unmet needs, such as access to medication, transportation to follow-up appointments, etc.
Send discharge summary and after-hospital care plan to primary care provider within 24 to 48 hours of discharge
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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
HOME CARE
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HOME CARE
NEED HELP? HERE’S WHAT WE DO…
WE WILL:
Sit with you in the hospital 24/7 Provide transpor tation home Stay with you in your home 24/7 Help you with personal care Take you to your appointments Help you with medications Prepare your food Keep your surroundings clean and safe
DON’T FEEL GUILTY IF YOU CAN’T DO IT ALL! Professional Caretakers 50 Briar Hollow Lane, Suite 260 Houston, TX 77027
(877 ) 921- 9500
WWW.PROFESSIONALCARETAKERS.COM Serving Texas since 1988 Licensed – Bonded Non-Medicare
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HOME CARE
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HOME CARE
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Please see ad on page. 7
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HOME HEALTHCARE
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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>Þ°Ê -‡££äxLJ£ÎÊ £äx
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HOSPICE
Beaumont
409-832-6700
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Houston
Houston North
281-277-1151 210-520-7734
HOSPICE
Is persistent overcrowding a problem for your ED?
VITAS breaks the cycle
A recent survey by the American Hospital Association reveals more than 50 percent of surveyed urban and teaching hospitals had EDs that were at or over capacity.1 VITAS care transition support services can help keep your beds turning. • We offer clinical staff trained to discuss goals of care and hospice benefits. • The VITAS admission team is available 24/7. • We can alleviate congestion in EDs by transitioning end-of-life patients to home. • VITAS can provide 24-hour nursing care (continuous care) in the patient’s home, nursing home or assisted living community, when appropriate, to control symptoms • VITAS after hours program provides direct, 24-hour access to clinical experts who have patient information and can dispatch a team member to the bedside any hour of the day or night, even on holidays. A referral to VITAS expands alternatives for transitioning your end-of-life patients.
1.800.93.VITAS • VITAS.com/Texas 1
American Hospital Association “Taking the Pulse: The State of America’s Hospitals.” Results of AHA Survey of Hospital Leaders, March/April 2010-May 24, 2010.
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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
When Compassion Counts, Count on Us. Easy Access - Admissions 24/7
Short-Term Rehabilitation | Complex Medical Care Long Term Care 24/7 Skilled Nursing Care | Physical Therapy Occupational Therapy | Speech Therapy | IV Therapy Comprehensive Wound Care Nutritional Therapy | Respite Care | Hospice Care Discharge Planning
Oakmont Healthcare & Afton Oaks Healthcare Rehab Center of Katy & Rehab Center 1525 Tull Drive 7514 Kingsley Katy, TX 77449-5099 Houston, TX 77087-4412 Phone: 281-578-1600 Phone: 713-644-8393
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Oakmont Healthcare & Rehab Center of Humble 8450 Will Clayton Pkwy Humble, TX 77338-5830 Phone: 281-446-8484
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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PRIVATE DUTY NURSING
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REHABILITATION HOSPITAL
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