In-Home Care Management
The SeniorBridge In-Home Care Management Program is our flagship product and provides ongoing support to people with complex conditions and multiple chronic illnesses.
The service has been proven to substantially improve outcomes and reduce cost of care of those with frequent emergency room visits and hospitalizations.
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SeniorBridge licensed nurse and social worker care managers assess health, functional and behavioral status, establish diagnoses, develop individualized care plans, and coordinate medical care with physicians, healthcare providers, family members and managed care organization case managers all of which is documented in SeniorBridge's proprietary electronic health record (Rosalind©).
Program services include:
Evaluation and Management
- Medical conditions
- Functional capability
- Behavioral problems
- Medication Reconciliation
Care Management
- Face-to-Face care management
- Tele-Care management including biometric monitoring, if indicated
- Collaboration and coordination with family, physicians and healthcare providers, managed care organization case managers and patient support system
- Family and patient education
- Support of caregivers
- Home safety plan
- Medication visualization and management
- Fall prevention training
- Nutritional advice
- Depression screening and counseling
- Palliative care support
Coordination and Coverage
- Coordination of care with physicians, health care providers, hospital discharge planners and Health Plan case managers
- Transitions from Hospital or Emergency Room to Home
- Care manager on-call 24 hours per day, 7 days per week