With industry-leading technology by CareSync and "In person" care coordination services we turn the overwhelming task of Transitional Care Management (TCM) and Chronic Care Management (CCM) into an opportunity to improve patients’ experiences, medical outcomes and provider profitability. Our Advocates assist discharging patient from the hospital/post acute setting to home, as an extension of your facility to prevent costly readmissions. We implement your discharge plan, start TCM with the primary care physician, medication reconciliation & coordination of services needed by the senior. Providing a comprehensive report of care activities at the end of 30 days. Post discharge we provide a turnkey solution for the physician to not only better manage and increase the quality of care for their patients, we guarantee a compliant revenue generating solution for on going Chronic Care Management. "Medicare beneficiaries with multiple chronic conditions are the heaviest users of health care services, including such high-cost services as hospitalizations and emergency department visits, which translates into increased Medicare spending. Two-thirds of beneficiaries with 2 more chronic conditions accounted for 93% of Medicare spending." Families find themselves overwhelmed by the numerous options when looking for care, be it DME,non medical in home care or placement. The most difficult problem seniors face is how to coordinate, find and then pay for care. 1)We provide family advocacy and team case management 2)Coordination with family, facility, doctors and providers 3)Financial counseling for "Cost of Care" 4)Finding care "In Home" or "Placement" 5)Finding ways to pay for quality care Our team of experts help with both the clinical and financial problems that come with this process. We have experts in Nursing, Social Work, Case Management, Financial Advisors, Placement Specialist, Senior Real Estate Experts and Medicare/Health insurance advisors.