Care Coordination

Care transition coordination
A transition of care is when a patient moves between care settings, such as when a patient leaves the hospital and returns home or goes to a rehabilitation facility. Care transitions also occur when a patient’s condition or situation changes. We provide the coordination during care transitions that helps prevent problems such as medication errors or failure to transfer important information.

Coordinate services with other members of the health care team
Research shows that patients who receive treatment under a coordinated care system such as the patient-centered care model our care manager use experience better outcomes across the full spectrum of aging issues. A few examples:

  • Emergency room visits and hospital admissions are reduced by at least 50% among high-risk elderly patients
  • The reduced functionality usually associated with hospital discharges of the elderly is mitigated
  • Agitation in Alzheimer’s patients is reduced with a correlated reduction in caregiver stress.

Source: US Dept. of Health and Human Services. Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Locate and coordinate community resources
Many families contact Umbrella when they’re at a loss as to the best course of action to take for an ill or injured senior adult. One of the primary functions Umbrella serves is to ensure the patient’s best care while engaging community resources to alleviate caregiver stress and financial burden. These resources may include government, non-profit and private programs. We often find that our fees are offset by the community and entitlement benefits we find for a patient.

Coordination and supervision of in-home care and companion services
When home care is required for elderly or disabled persons, we are happy to refer families to trusted providers. Regardless of the referral source, however, home caregivers are entrusted to work otherwise unsupervised in patient’s homes. Umbrella care managers can provide you peace of mind by regularly conducting unannounced visits to ensure quality of care and hold caregivers accountable to a third party.

Quality assurance monitoring at acute and long-term care facilities
Without a medical background or sufficient time to regularly evaluate the care a loved one is receiving at a long term care facility, family members may find comfort in receiving objective care evaluations from Umbrella care managers. Such evaluations can be routine or on an as needed basis to address particular concerns.

Regional network of financial experts
The fact that many older adults fail to plan for their eventual declining health can be catastrophic to family assets. Our comprehensive assessment includes an evaluation of a patient’s legal and financial preparedness respective to their current medical condition. When appropriate, we are able to provide referrals to our regional network of attorneys who can advise clients on options to preserve assets and obviate legal disputes.

National referral network
No matter where you’re located, we’re happy to answer questions and refer you to a trusted NAPGCM affiliate anywhere in the country.