For Discharge Planners, Case Managers, and Senior Care Professionals
Atlantic AllCare is a CHAP-accredited non-skilled home care provider serving Broward and Palm Beach County. For discharge planners, case managers, and senior care professionals, we help make care plans hold at home through a documented referral standard, RN oversight on every case, structured status reporting, and direct long-term care insurance billing.
Whole Person Care Connection
Atlantic AllCare’s whole person care model gives referral partners one accountable partner for the daily, non-clinical factors that often determine whether a discharge plan or care plan succeeds at home: safe mobility, meals, medication routines, appointment follow-through, family communication, and early escalation when something changes.
What This Covers
The Atlantic AllCare Referral Standard gives every referred patient or client a consistent operating framework: targeted referral-to-care start within 48 hours, RN oversight on every case, direct billing to long-term care insurance carriers, CHAP accreditation through 2027, and CareScout Quality Network provider status.
Who This Serves
- Hospital discharge planners coordinating post-acute support
- Long-term care insurance case managers
- Senior care planners and financial advisors serving aging clients
- Elder law attorneys managing client care needs
- Geriatric care managers
- Hospital and health system social workers
Why Chap Accreditation Matters
CHAP accreditation through 2027 gives referral partners an independent, third-party quality signal for Atlantic AllCare’s caregiver training, supervision structure, and quality processes before a case is referred. That documentation can support the due diligence discharge planners and case managers need to show when selecting post-discharge support partners.
Payer or Benefit Callout
Atlantic AllCare bills long-term care insurance directly through the CareScout Quality Network for all major carriers. Atlantic AllCare is also an active VetAssist provider and a credentialed Curative Health Plan provider. VA Community Care Network credentialing through Optum Region 4 is in process, and Atlantic AllCare is awaiting an AHCA site visit to participate in Medicaid.
Non-Medical Is Not Non-Essential
Without consistent non-skilled support at home, clinical plans can break down in daily execution. Medications may go untaken. Falls may happen. Nutrition can deteriorate. Patients may return to higher levels of care. Atlantic AllCare provides the daily presence that helps clinical interventions hold after discharge
PDGM Bridge Partner Argument
PDGM stands for Patient-Driven Groupings Model, Medicare’s case-mix payment methodology for skilled home health services. It groups 30-day home health payment periods based on patient characteristics such as admission source, timing, clinical grouping, functional impairment level, and comorbidity adjustment.
HHVBP stands for Home Health Value-Based Purchasing, a CMS model that gives Medicare-certified home health agencies incentives to provide higher-quality and more efficient care by tying payment adjustments to quality performance.
For skilled home health agency referral sources, Atlantic AllCare can help patients maintain functional stability after a PDGM episode ends. Our caregivers support the daily routines connected to the eight OASIS ADL items that inform functional impairment classification. When patients remain more stable after discharge, agencies may be better positioned to reduce avoidable readmissions and support HHVBP performance goals. This is a co-referral relationship.
HCAHPS and Stars Support
Consistent non-skilled support after discharge can reinforce the Care Transition domain measured in HCAHPS by helping patients follow through on medication instructions and post-discharge guidance. For Medicare Advantage plans, Atlantic AllCare caregivers support daily medication adherence, help keep preventive care and follow-up appointments on schedule, and support chronic condition routines at home, all of which may align with Medicare Advantage Stars priorities.
Home Care Report Card
Atlantic AllCare is building a quarterly Home Care Report Card for referral partners, scheduled to begin in Q4 2026. The report card is intended to make service performance visible through metrics such as:
- Referral-to-care-start time
- Caregiver retention rate on case
- Fall incident rate
- 30-day rehospitalization rate for referred patients
- Medication adherence support rate
- Family and referral partner satisfaction score
- Escalation response time compliance
- Missed or late shift rate
- RN supervisory visit compliance rate
What Atlantic AllCare Reports Back to Referral Partners
Atlantic AllCare caregivers and RNs observe and escalate across eight defined categories on every case. Escalation timing is based on severity, ranging from immediate notification for urgent concerns to weekly summaries for lower-risk trends.
Observation Category
Escalation Timeline
- Functional status changes
- Skin integrity concerns
- Cognitive changes
- Nutritional concerns
- Medication adherence
- Fall risk and fall events
- Social determinants of health
- Family system stress
- Same day to weekly summary, depending on severity
- Immediate for new or worsening skin breakdown
- Same day to within 48 hours
- Within 48 hours to weekly summary
- Same day for missed or refused doses
- Immediate for a fall, same day for new risk factors
- Within 48 hours to weekly summary
- Within 48 hours to weekly summary
Quintuple Aim Alignment
Atlantic AllCare’s role in a referral partner’s care model maps directly to the five domains of the Quintuple Aim.
Domain
Atlantic AllCare Contribution
- Patient experience
- Population health
- Cost of care
- Care team well-being
- Health equity
- Consistent caregiver assignment and daily continuity at home.
- Ongoing monitoring supports earlier identification of decline.
- Non-skilled support reduces avoidable escalation and return visits.
- Structured reporting reduces uncertainty for referring clinicians.
- Home-based delivery reduces transportation and access barriers.
FAQ
Q1. How quickly can Atlantic AllCare start care after a hospital discharge referral?
Atlantic AllCare’s referral standard targets care start within 48 hours of a completed referral. Timing depends on completing an intake assessment, confirming benefits, and matching an appropriate caregiver, and Atlantic AllCare communicates status to the referring partner throughout that process.
Q2. What information does Atlantic AllCare share back with referring discharge planners?
Atlantic AllCare reports on eight categories: functional status changes, skin integrity, cognitive changes, nutritional concerns, medication adherence, fall risk, social determinants of health, and family system stress. Escalation timing ranges from immediate notification to a scheduled weekly summary depending on severity.
Q3. Does Atlantic AllCare accept long-term care insurance for referred patients?
Yes. Atlantic AllCare bills long-term care insurance carriers directly through the CareScout Quality Network and works with major carriers including Genworth, John Hancock, Transamerica, MetLife, Mutual of Omaha, Bankers Life, and Northwestern Mutual.
Q4. What is Atlantic AllCare's CHAP accreditation and why does it matter?
CHAP is a national accrediting body that independently reviews home care providers against standards for caregiver training, supervision, and quality processes. Atlantic AllCare is CHAP accredited through 2027, giving referral partners a documented, third-party quality signal before referring a case.
Q5. How does Atlantic AllCare support Medicare Advantage Stars measures?
Atlantic AllCare caregivers support daily medication adherence, help patients keep preventive care and follow-up appointments, and support consistent chronic condition routines at home. These daily, non-skilled supports may align with Medicare Advantage Stars priorities related to adherence, follow-through, and chronic condition support
To discuss a current patient, coordinate a discharge-related referral, or establish an ongoing referral relationship, call Atlantic AllCare directly. Broward: (954) 427-4546. Palm Beach: (561) 912-9511.
Ask to be added to the Home Care Report Card distribution list ahead of its Q4 2026 launch.