consumers require complex care management

we visit last week http://towsonmd.brightviewseniorliving.com/CommunityHome.aspx .. and please answer these questions  

Now that we know about residential and home and community-based long term care services in the US, we need to look at how consumers transition from one type of care setting to another, including transitions from the hospital to these settings. These transitions have become increasingly important with greater emphasis on reducing hospital readmissions and increasing patient and resident safety under the ACA.

1.  What types of consumers require complex care management as they move through the various dimensions of long-term care services?  Name and describe at least two risk factors that can increase hospital readmissions for these individuals.

2.  Name at least two of the American Geriatrics Society recommendations to improve transitional care for consumers, and explain why these factors are important for health care providers to consider.  What is a transition plan, and why is this important for health care providers to put into place for consumers?

3.  How can greater attention to a consumer’s level of pain or a consumer’s probability of having a dementia diagnosis help care transitions?  Can contact with a consumer’s caregivers (if they have them) improve the care transition process.

answer in 250 words at least