Post-Acute Care Partners is designed as a continuum of services dedicated to supporting our patients and clients in and outside of any and all acute and post-acute care environments. The inception of this concept comes from the recognition that care and care coordination is extremely fragmented as patients with chronic conditions navigate through hospitalizations, skilled nursing stays and other healthcare environments. Additionally, healthcare costs continue to rise while quality outcomes decline. A patient’s health, wellness and quality of life can all be increased through a team of healthcare professionals dedicated to guiding patients through a wellness approach as opposed to just responding to chronic conditions as they occur. PACP HomeCare serves as the initial entity as it is the most agile niche within the healthcare industry. The Physician element is the most critical component of PACP. Concierge and HouseCall Physicians add an oversight to the HomeCare model that is unheard of. Additionally, they are the driving force in the assurance of care delivery specific to patient centered care plans and overall patient’s health and wellness. Physicians have the ability to drive outcomes, increase patient satisfaction and improve quality of life serving essentially as the “quarterback” to the entire care team. The Geriatric Care Management, Home Health and Hospice components will initially be subcontracted with the intent of holding these providers accountable to PACP standards until such entities are acquired or developed as a start-up in later phases. See figure A below representing the entire continuum of services PACP seeks to offer. Take note that the HomeCare and Physician components serve as the core of the organization while additional service offerings are added via start-up or acquisition.
At Post-Acute Care Partners, we believe in order to establish industry standards in the concepts of personalized medicine focused wholly on each individual member, an entire continuum of care is required as each member has extremely unique and diverse care needs based on many components. In order to be successful, the continuum MUST have the unique ability to meet the following requirements:
- Care must be specifically tailored to each member
- Care delivery is so focused on quality that it establishes industry standards. Care delivery with love, empathy and compassion drives increased quality of life for members.
- Care must be delivered in any environment I.E. home setting, hospital, skilled nursing, assisted living facility and in transition between each.
- Care coordination must be seamless. Defragmentation of current acute/post-acute care coordination is our goal.
- Care transitions MUST be seamless. Transitioning from one care environment to another is critical to continued healing and better outcomes.
Post-Acute Care Partners will establish a Home Care organization as the initial entity. The services offered will be as follows:
- Personal Care Aides or Personal Attendants to provide the following services/care needs:
o Companionship – The most important aspect of caregiving is in creating a relationship built upon trust and love. Engaging our clients in being active with living with purpose increases their quality of life.
o Activities of Daily Living (ADL’s) – Bathing, toileting, grooming, dressing, eating, transferring
o Transportation – whether a trip to the grocery store, shopping, the bank or home from the hospital, our PCA’s either provide the transportation or provide the companionship and oversight through a transition from one environment to another.
o Medication monitoring – Keeping our clients on their medication regimen through reminders
o Light housekeeping, meal preparation and basic needs in the home
o Care plan adherence – Care plans are created and each client’s unique and diversified needs are identified through the Client Onboarding Assessment (COA).
The target audiences are as follows: Adult decision makers of any age seeking short or long term in-home companion services to care for themselves or care for a spouse or loved-one. In addition, physicians, hospital discharge planners, and care managers seek to support a patient that needs immediate companion support while hospitalized or more importantly at discharge to assure a safe and coordinated transition to the place the patient calls Home.