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Collaborative Outpatient Management for Palliative and Aging Support Services
The COMPASS Program (Collaborative Outpatient Management for Palliative and Aging Support Services) is a comprehensive, in-home medical care program designed for older adults living with multiple chronic or complex medical conditions.
Built specifically for medically high-risk seniors, COMPASS provides structured, proactive healthcare management focused on improving outcomes, reducing preventable hospitalizations, and supporting long-term stability — all in the comfort of home.
This is not episodic care. It is coordinated, team-based, ongoing medical oversight.
What Is The COMPASS Program?
The COMPASS Program is a specialized in-home primary care and case management model for seniors who require frequent monitoring, chronic disease management, symptom control, and coordinated care across providers.
We function either:
>As a patient’s primary care provider, or
>As a collaborative extension of an existing primary care team
Each patient receives a dedicated care team and structured monthly engagement to ensure continuous oversight and early intervention.
Who Benefits from COMPASS?
The program is designed for:
>Seniors with multiple chronic conditions
>Individuals with dementia, CHF, COPD, Parkinson’s, diabetes, or other serious illnesses
>Patients needing palliative care but not hospice
>Homebound individuals wanting to avoid unnecessary hospitalizations
>Families struggling with care coordination
>Patients requiring behavioral health support
COMPASS is especially valuable for seniors at high risk of emergency department visits or hospital readmissions.
How the COMPASS Model Works
Patients enrolled in the COMPASS Program receive:
- Monthly In-Home Visits: A dedicated nurse case manager visits the patient at least once per month in the home.
- Facilitated Telemedicine Visits: During the in-person visit, the nurse case manager facilitates a telemedicine appointment with an advanced practice provider (PA or NP), ensuring direct medical evaluation and care plan updates.
This structured cadence allows us to:
>Identify clinical changes early
>Close care gaps
>Improve medication adherence
>Coordinate specialists and services
>Reduce preventable ER visits
>Lower hospital readmission rates
Core Services Within COMPASS
The COMPASS Program integrates multiple services under one coordinated model:
>In-Home Primary Care
>Medical Care & Sick Visits
>Chronic Disease Management
>Symptom Control
>Medication Management
>Vital Signs Monitoring
>Behavioral Health Services
>Telemedicine & Remote Health Care
>Palliative Care Support
>Post-Hospitalization Follow-Up
We also coordinate allied services when needed, including home health, therapy services, and hospice.
When Should You Consider COMPASS?
Enrollment may be appropriate if you or your loved one:
>Has multiple chronic conditions requiring close monitoring
>Struggles coordinating care between providers
>Experiences frequent hospital visits
>Needs palliative-level symptom management
>Requires behavioral health support
>Wants to remain safely at home with structured medical oversight
Earlier enrollment often leads to better stability and improved long-term outcomes.
Billing & Insurance
COMPASS services are billed to the patient’s insurance and are covered under Medicare Part B.
Co-pays may apply. Prior to enrollment, we fully review cost-sharing responsibilities to ensure complete transparency.
Keep Your Primary Care Physician
Patients may keep their existing primary care provider or choose COMPASS as their primary medical team. We are designed to collaborate — not disrupt — continuity of care.
When Should You Consider COMPASS?
Enrollment may be appropriate if you or your loved one:
>Has multiple chronic conditions requiring close monitoring
>Struggles coordinating care between providers
>Experiences frequent hospital visits
>Needs palliative-level symptom management
>Requires behavioral health support
Earlier enrollment often leads to better stability and improved long-term outcomes.
Contact & Referrals
For referrals or additional information:
Phone: 888-982-8594
Fax: 888-920-1525
Email: referral@seniorityhealthcare.com
COMPASS Program FAQs
The COMPASS Program (Collaborative Outpatient Management for Palliative and Aging Support Services) is a comprehensive in-home healthcare program designed for seniors with multiple chronic or complex medical conditions. It combines in-home primary care, nurse case management, telemedicine visits, and coordinated medical oversight to improve health outcomes and reduce unnecessary hospitalizations.
The COMPASS Program is ideal for older adults managing multiple chronic conditions such as heart failure, COPD, diabetes, dementia, or Parkinson’s disease. It is especially helpful for seniors who require frequent medical monitoring, need help coordinating care between providers, or want to remain safely at home while receiving structured medical support.
Patients enrolled in the COMPASS Program receive monthly in-home visits from a nurse case manager who facilitates a telemedicine appointment with an advanced practice provider. This structured care model allows the clinical team to monitor health changes, manage medications, coordinate specialists, and address new symptoms early to prevent complications.
Yes. Patients can keep their existing primary care physician while participating in the COMPASS Program. Seniority Healthcare can work collaboratively with the patient’s current providers to coordinate care, manage chronic conditions, and ensure all healthcare teams remain informed and aligned.
COMPASS services are billed to the patient’s insurance and are covered under Medicare Part B. Depending on the patient’s insurance plan, co-pays may apply. Before enrollment, the Seniority Healthcare team reviews all potential cost-sharing responsibilities to ensure patients and families understand their coverage.