We Can Help Reduce Readmissions

ACUTE REHAB DISCHARGE

When a patient has completed their Medicare-covered stay at your facility, but is still not ready to be home alone, a short-term transitional stay in Assisted Living offers a holistic approach to sub-acute rehab with continued PT, OT or other services.

HOSPITAL DISCHARGE

We know that readmission penalties are a major concern for you, with 1 in 5 elderly patients returning within 30 days. Assisted Living is a solution, offering a perfect transition between hospital and home, when a rehab stay isn’t a necessary first step.

A short-term respite stay in Assisted Living, which bridges the gap between hospital or rehab and home, can provide the extra care, support and time one needs to fully recuperate, and can give families the time they need to organize post-hospital care so that their loved one returns to a safe environment with all the right supports in place.

Let us partner with you in the continued care of your discharged patients. The safety of the environment in which a senior recuperates and the quality of oversight they receive play a critical role in reducing readmissions and supporting their success.

Who Can You Refer? You Might be Surprised.

Assisted Living is appropriate for your elderly patients needing:

  • Oxygen
  • Therapeutic services (PT, OT, speech therapy)
  • Special diet requirements (even pureed diet)
  • Hospice and palliative care
  • Oversight managing multiple chronic conditions, including Diabetes and Parkinson’s Disease
  • Assistance/transferring from wheelchairs

Here’s How We Help Make Your Job Easier:

Same Day Assessments, Fast Track Move-Ins, No Minimum Length of Stay



  • Fast track assessments and move-ins 7 days a week
  • No hospital qualifying stay required
  • No minimum length of stay required
  • Contact an SLR community directly to arrange an assessment for your patient

Coordination of Follow-up Care by Assisted Living Nurses



  • Assisted Living nurses provide supervision and serve as a liaison with patients, families, physicians, visiting nurses, therapists, and others in post-discharge care
  • Discharge recommendations, outstanding tests and physician visits are coordinated by Assisted Living nurses
  • Skilled nursing and therapeutic services are provided onsite by outside agencies (billed to Medicare):
    – Oxygen, post surgical wounds, insulin management
    – PT, OT, speech/language therapy
  • Medication reconciliation and management are coordinated by Assisted Living nurses
  • 24/7 licensed nursing assistants (CNAs) provide ADL/IADL support
  • 24-hour awake staff ensures immediate response to “unscheduled” patient care needs
  • Special diets and other nutritional support can be accommodated
  • Physicians and nurse practitioners often conduct “house calls” to Assisted Living communities

Advantages of Recovering in a Residential Environment, with a Fully Furnished Apartment



  • A fully furnished private apartment with private bath for all Respite Stays
  • Care and services are provided discreetly in the privacy of a resident’s apartment
  • The ability to engage in stimulating programming eliminates isolation. Camaraderie, laughter and involvement in activities one enjoys helps foster well-being and hasten recuperation
  • Restaurant-style dining improves nutrition and enhances well-being
  • Recuperating in a supportive social environment boosts motivation to be active and engage in therapies with staff oversight and peer encouragement

Expert Support for Patients with Dementia



  • Renowned Compass Memory Support program offers non-pharmacological researched-based treatment
  • Nutrition/dehydration needs are addressed

Financially, Assisted Living can be a good option compared to HHC and SNFs



  • A less expensive option to 8 hour + private pay home care and nursing home care
  • SLR Executive Directors work closely with referral sources to determine if a financial program, such as the Veterans Benefit, would benefit a patient
  • On-site staff coordinates with local healthcare providers for Medicare-reimbursed services to keep residents’ healthcare costs down

Assisted Living Resident Profile 

  • 87 years old
  • Needs help with ADLs (activities of daily living): 72% with bathing, 50% with dressing
  • Needs assistance with IADLs (independent activities of daily living): 80+% with med management & meal prep
  • 75% has several of the top 10 chronic conditions: 57% high blood pressure, 40% dementia. Also: heart disease, depression, arthritis, osteoporosis, diabetes, COPD, cancer, stroke
  • Most take 5+ medications per day
  • Many have special diet requirements
  • Mobile, but walkers and wheelchairs are common
  • Many receive therapeutic services, such as PT, OT, speech therapy
  • Some require agency skilled nursing services, including wound care and hospice/palliative care
  • 70/30 split female/male

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