OUR SERVICES

Transitions Care Management, LLC offers a wide array of services aimed at providing comfort, safety, fulfillment, and quality of life. 

CARE MONITORING 

Oversight and coordination of care for clients in a variety of settings. These services can include, but are not limited to:

Review existing care plan

Develop Life Care Plan

Review medical records

Coordinate and attend medical appointments

Communication with physicians and specialists to ensure continuity of care

Assist with bill paying and record keeping

Support and education for families and caregivers

Referral to ancillary services such and Physical and Occupation Therapies, Nutritionists, Massage Therapists, etc.

Monitor quality and appropriateness of services

Coordinate screening and hiring of caregivers via known staffing and registry organizations

Medication management

 

 

ASSESSMENT AND LIFE CARE PLAN

A Certified Aging Life Care Professional™ will provide a complete assessment of all aspects of the client's life including:

Chronic and acute physical conditions

Mental health and cognitive conditions

Family dynamics and support systems

Personality inventory and personal preferences

Changes and losses

Social and psychosocial needs

A unique Life Care Plan will then be developed addressing the client's short and long-term goals that takes into consideration the client as a whole.

 

 

MEDICATION SERVICES

(Can be contracted independent of Care Monitoring services)

Monthly/weekly RN visit to fill medication sets

Monthly medication management record

Individualized medication identification/precautions sheet

Monthly in-home review of medications and recommendations for improvement

RN telephone support for medication related questions

OTHER SERVICES

Transitional services to support the client home from a hospital or rehabilitation stay

Relocation services

Nurse delegation (for ongoing care monitoring clients only)

Expert consultation

Home safety assessments

Crisis intervention

Available 24/7