We will meet with you to explore current challenges and future planning needs. During the consultation, we will provide education and referrals. Family consultations can be done in person or virtually.
Ongoing Care Management
We will meet with you and your loved one to perform a comprehensive assessment and develop a customized care plan. In addition, we assess your needs regularly and provide ongoing advocacy, support, and care coordination.
Care management includes, but is not limited to:
- Implementing care plan recommendations and revising the care plan as circumstances change.
- Attending doctor appointments and facilitating communication between doctor, client, and family.
- Linking with appropriate service providers and monitoring those services (e.g., home health, senior companion, hospice, elder care attorney, bookkeeper.)
- Providing information on Federal and state entitlements, connecting families to local programs when appropriate (e.g., food assistance, veteran’s benefits, Medicaid.)
- Helping the client and families with insurance concerns, claims, and applications.
- Evaluating home safety and helping the client and their family select an appropriate level of housing or residential options.
- Helping families adjust, cope and problem-solve around long-distance and in-home caregiving.
- Acting as a liaison to out-of-town families, making sure things are going well, alerting families to problems, and providing expertise for solutions.
- Offering crisis intervention when needed, helping the client navigate emergency departments and hospitalizations, rehabilitation stays, and ensuring appropriate care is available to the client.
- Offering ongoing counseling, support, advocacy, and education.
On-Call Care Management
You or your loved one may not need regular ongoing care management services right now, but you recognize the need to be prepared for future needs that may require professional support and advocacy. In this circumstance, we would meet with you to establish a relationship, gather relevant social and medical history, and review long-term care planning needs. If there is a change, such as in health status, if a local caregiver goes out of town or becomes ill, or you require crisis intervention, we will be available to respond. When everything is stable, a quarterly home visit or telehealth call will ensure information is updated.