Call for your complimentary initial consultation       •        (321) 752-0995        •       Serving Brevard County
   Care Transition Services
BRIDGING THE GAP WITH THE 4 C'S
COLLABORATION within all health/social
realms and with providers
COMMUNICATION with Patient and Family
COORDINATION of dischage with community
healthcare providers
CONTINUITY of care over the health care continuum
PROGRAM PROCESS
  • Identify the at-risk individuals and caregivers
  • Connect at-risk with transitional staff prior to discharge
  • Facilitate interdisciplinary health/social team communication
    and coordination
  • Patient education to ensure understanding of the discharge
    plan and process
  • Connect with key community players, services, and supports
    prior to discharge appropriately to adverse symptoms post-
    discharge
COMMUNITY PARTNERS
    TLCCS CARE MANAGERS can bridge the social and medical
    arenas effectively and efficiently with a holistic focus on each
    client's individual needs, goals, and resources for their
    discharge back home.  TLCCS CARE MANAGERS are experts
    in care planning and management designed to maximize the
    health, independence, resources, and quality of life for
    persons with an acute or chronic illnesses and/or a disability.

    Individualized care planning and management are essential in
    resources and addressing individual goals.  TLCCS CARE
    MANAGERS can accomplish this by assisting with:

  • Patient and family Education and engagement
  • Development of a post discharge follow-up plan
  • Transitional planning for follow-up care
  • Engagement of and communication among patient's
    community healthcare provider(s)
  • Medication Management
  • Coordination and management of family/community care
    providers


    TLCCS CARE MANAGERS emphasize coordination and
    continuity of care, prevention and avoidance of complications
    and close clinical oversight AND care management --
    accomplished with the active engagement of patients, their
    family and caregivers, and the collaboration with the patient's
    healthcare providers.
Total Long-Term Care Consultant Services, Inc.
Serving Brevard County
P.O. Box 411928, Melbourne, FL 32941
Tel 321-752-0995  |  Fax 321-369-9953  
E-mail:  info@tlcconsultantservices.com

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