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Cómo hacer una referencia:
¡Puedes referirte tú mismo!

At Senior TLC, we understand that every individual’s care journey is unique—and so is your commitment to finding the best support for them.

 

As a PACE program, we specialize in providing holistic, head-to-toe care for seniors who wish to remain safely in their homes and communities. Whether the need is medical, social, or supportive services, you can trust us to be a reliable, compassionate resource for the individuals you serve.

 

Make a referral today and help your clients access the care they deserve—with dignity, respect, and the support of a dedicated interdisciplinary team.

Patient Information

Birthday
Día
Mes
Año
Patient is interested in

Caregiver/Decision-Maker Information

Is there a caregiver or family member involved in making healthcare decisions?
Yes
No

Eligibility Checklist

Age 55 or older
Currently enrolled in or eligible for MEDICARE
Currently enrolled in or eligible for MEDICAID
Meets nursing home level of care due to functional or medical need and is challenged to perform two or more Activities of Daily Living (ADLs)
Resides in a PACE service area (certified ZIP code)
Able to live safely in the community with support from PACE

Chronic Conditions & Health Events

Diagnosed with two or more chronic conditions (e.g., diabetes, COPD, CHF, arthritis, dementia, stroke)
Experienced a fall in the past 6 months
Visited the ER in the past 6 months
Admitted to hospital or rehab in the past 6 months
Has difficulty attending or coordinating medical appointments

Activities of Daily Living (ADL) Assessment

Bathing: Help set up? Supervision? Shower chair?
Dressing: Choose clothes? Upper/lower body?
Grooming: Shaving, oral care, nail clipping
Mobility: Needs assist device (walker, cane, wheelchair)?
Eating: Feed self? Choking risk? Uses utensils?
Meal Prep: Uses stove/microwave safely?
Medication Management: Needs reminders or help taking meds?
Memory/Cognition: Forgetful, confused, wandering, safety risk
Phone use: Can make or answer calls independently?
Supervision/Safety: Falls, lives alone, emergency awareness
Transferring: Bed/chair/wheelchair/toilet transfers

Transportation

Mode of Transportation

Referral Submission

Referral Source/Organization
Date
Día
Mes
Año

Disclaimer: This form is for screening purposes only. Final eligibility for PACE is determined through a comprehensive assessment conducted by the PACE organization and applicable state agencies 

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