Seamless Transitions. Fewer Readmissions. Exceptional Home Care.
Physician-led transitional care in the patient’s home
Problem & Solution
The Transition Challenge:
Hospital discharges are high-risk. Fragmented care, medication errors, and lack of follow-up lead to complications and readmissions; patients and families often feel overwhelmed navigating post-acute care.
The SeniorCare Home Solution:
We bridge the gap with physician-led care in the home—managing medical complexities, optimizing medications, and coordinating services to reduce risks and improve outcomes.
Services
In-Home Physician Visits
Comprehensive assessment within 24–72 hours of discharge; personalized care plans; coordination of labs, imaging, and diagnostics.
Advanced Medication Management
Full reconciliation of prescriptions, OTC, supplements, herbals; deprescribing; adherence education; proactive interaction and side-effect screening.
Access to Specialists
Cardiology, Pulmonary, Digestive Health, Psychiatry, Palliative Care, Pain Management.
Why Partner
Reduce readmissions
Enhance safety and outcomes
Boost patient/family satisfaction
Simplify discharges
Support safe transitions
Integrated Care Coordination
Collaborate with home health nurses, therapists, aides
Arrange DME and community resources (Meals on Wheels, etc.)
Central contact for patients, families, PCPs, specialists, hospitals
Ideal Referral Candidates
Frequent hospitalizations / ED visits
Complex conditions: CHF, COPD, Diabetes
Polypharmacy (10+ meds, high-risk regimens)
Limited social support or transportation
Specialist follow-up needs
Palliative care or pain management
