For Discharge Planners/Case Managers

We can help you ease the transitions of care. You have many responsibilities to juggle as you prepare patients and residents to leave the skilled medical setting and finish their recovery safely at home. It’s hard to know what the family members will retain, what they can realistically manage, how well the patient and family will adjust to the new medication routine, etc.

For those families with resources to assist, we can provide the continuity, the safety net, to be sure that the transition unfolds smoothly and that the patient does not end up back in the hospital a few weeks later.

Our clients receive state-of-the-art support at home with

  • In-home medication management and follow-up
  • Monitoring of signs and symptoms of relapse
  • Family caregiver education and support
  • Advocacy with physicians to assure follow-up appointments
  • Coordination of care services from multiple providers
  • On-going care management in collaboration with a legal guardian or conservator
  • Facilitation of family meetings and communication with long-distance relatives

If you are concerned that a family needs more support in order to avoid a readmission, give us a call at 650-879-9030. We accept private pay clients and, depending on insurance coverage, our services may be reimbursed by long-term care policies.

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Online educational resources

The discharge process is frenzied and stressful. Families try to concentrate, but sometimes it’s more than they can take in all at once. That’s why we support you with online educational articles on high re-admit common conditions such as congestive heart failure, COPD, and dementia. Bookmark this website! These materials are available for you, 24/7 to print out and give to your clients as part of the discharge process.

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