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Care Transitions

In July of 2013, SeniorServ launched a new Community Care Transitions Program demonstration project. It is supported by the Center for Medicare and Medicaid Services (CMS).

SeniorServ is partnering on the project with four area hospitals: Anaheim Regional Medical Center; St. Jude Medical Center; University of California Irvine Medical Center and Western Medical Center, Santa Ana.

The goal of the project is to reduce hospital readmissions. The program incorporates care coordination including pre-discharge assessment of the patient, early identification and response to health care risks and symptoms, education and support of patients and their families, home visits with telephone support and ongoing communication among all parties. 

SeniorServ has hired Care Navigators who will work closely with at-risk patients identified by our hospital partners. Services provided will include coaching, Care Transitions Interventions developed by the Erick Coleman model, home delivered meals, and transportation services if needed.

For More Information Contact

Adriana Bermudez, Care Transitions Program Manager
abermudez@seniorserv.org
(714) 220-2114