St. Vincent’s Transitional Care Program is dedicated to providing comprehensive medical care for individuals choosing to age in place. Our team of experienced physicians and advanced practice professionals specializes in delivering both acute and chronic care services tailored to the unique needs of the aging population within their existing living environments. We focus our expertise specifically on supporting:
- Long-term residents of nursing homes requiring consistent and attentive medical oversight.
- Individuals in skilled nursing facilities for short-term acute stays, where we provide expert medical management and rehabilitation service supervision.
- Patients residing in assisted living and independent living facilities who benefit from specialized chronic care management.
Our skilled nursing and long-term care services are designed to offer a complete spectrum of healthcare support, including:
- Chronic Care Management: Proactive and ongoing management of chronic health conditions to improve patient well-being and quality of life.
- Specialty Service Collaboration: Seamless coordination with various medical specialists to ensure holistic and integrated patient care.
- Durable Medical Equipment (DME) Services: Efficient referral and ordering processes for necessary medical equipment to enhance patient comfort and mobility.
- Diagnostic Testing Services: Convenient access to mobile laboratory and X-ray services, bringing essential diagnostic capabilities directly to the patient.
Understanding Chronic Care Management with St. Vincent’s
For individuals with Medicare, or dual Medicare and Medicaid eligibility, managing two or more chronic conditions while living in assisted or independent living facilities can be simplified through St. Vincent’s Transitional Care Program. Medicare’s Chronic Care Management (CCM) services, facilitated by our program, are designed to alleviate the complexities of healthcare management, allowing you to focus on enjoying life.
Our CCM services offer significant benefits:
- Dedicated Healthcare Team: A committed team of healthcare professionals actively participates in planning and supporting your health journey. This includes regular monthly check-ins and readily available access to the care team for proactive management of care transitions, specialist referrals, and necessary follow-up appointments.
- Comprehensive Personalized Care Plan: We develop a detailed care plan tailored to your specific needs and health goals. This plan addresses various aspects of your well-being, encompassing physical, mental, cognitive, psychosocial, functional, and environmental factors to effectively support disease control and overall health management.
- Annual Medicare Wellness Exam: Access to annual wellness exams covered by Medicare, focused on preventive care and maintaining your optimal health.
- Advance Care Planning Assistance: Guidance and support in advance care planning, ensuring your healthcare wishes are understood and respected.
St. Vincent’s Transitional Care Program is committed to enhancing the healthcare experience for aging individuals, providing expert medical support within the comfort of their familiar living environments. We strive to deliver patient-centered care that promotes health, independence, and overall well-being.
