SNF Transitional Care

Transition Care Managment

Watch To Find Out How We Can seamlessly Coordinate Your Transitional Care..

Contact Us To learn More

or schedule an in service for your facility..

Skilled Nursing Homes have strong financial incentives to prevent hospital readmissions, Monitoring resident post-discharge care has become a priority in our new "value driven" healthcare system

Senior Home Advocates offers post discharge coordination and discharge plan implementation via “live in person advocates” to assist seniors and families navigate the 30 days post discharge


  • Decreased Readmissions
  • Decreased Mortality
  • Increased Physician Follow-Up
  • Increased Undersanding
  • Decreased Client/ Caregiver Stress

With over 20 years of experience in the healthcare industry we have experience in all areas of the Transitional Care Process. Our team of experts is able to increase communication and provide service to not only the patient but the facilities and doctors as well.


  • For Doctors
  • For Facility
  • For Resident

Track patients post-discharge

CareSync platform as a tool for care coordination

Provide a “marketable” TCM program to referral source

Prevent readmissions

Increase of Care Value to resident and family

Provide hospital/SNF with real time tracking of discharged patients

Expected Outcomes.

Promote wellness and increased resident satisfaction post discharge by monitoring and implementing the facility “discharge plan/transition strategy” for a minimum of 90 days

Create interoperability amongst “circle of care” post discharge to include physicians, home health providers, non medical care providers, pharmacy and family

Prevent avoidable readmission and reduce unintended healthcare outcomes

Create safe and sustainable transitions - prevent transitions failure

Measure meaningful data and report resident outcomes/satisfaction 90 days’ post discharge

We Help Lower Risk of Readmissions..

A patient-centered solution that combines industry- leading technology and 24/7 care coordination services. Senior Home Advocates provides turnkey Transitional Care Management .

Contact Us Today To Find Out How We Can Be Of Service To You (714)921-9200.