AVAILABLE SERVICES

Assessment

In-home assessment (financial, legal, medical, home safety, caregiver support, cognitive, psychosocial, depression screening) in order to determine a Long Term Life Care Plan.

Read more about initial assessments.


Long-Term Life Care Plan

Life Care Plan - Complete written recommendations individualized to client, including medical, legal, financial, home safety, resources in community, community placement, referrals to multiple companies for in-home support

Review of financial, medical and legal issues with referrals to appropriate agencies

Referrals and coordination of all services (skilled home care, non-skilled home care, durable medical equipment, counseling, MD, rehab, dietitian, housing, legal, financial services)

Family consultation and mediation

Education and overview of services in healthcare to save money and time

Provision of community resources and setup of Emergency Response System (e.g. Lifeline)

Education on advance directives


HEALTHCARE ADVOCACY

Provision of "Total Care" for the patient

Education, support and guidance for patient, caregivers and families to cope with the effects of the patient's disease

Focus on strategies for increasing a patient's quality of life

Coordination of care with physicians, home care, families, facilities and communities

Creation and maintenance of a medication/allergy/medical history list for MD visits

Liaison for patient at all MD appointments

Dispute resolution with healthcare providers and insurers

Bill management and bill pay; balancing of accounts

Focus and education on patient rights, matters of privacy, and confidentiality

Read more about healthcare advocacy.


Discharge Planning

especially ideal for complex cases where limited or no family is involved or family is at a distance

Coordination and communication with physicians, insurers, families and specialists

Implementation of Collaborative Care Program (meeting with family; assessment of discharge needs; implementation of Care Plan; assistance from Care Manager and caregiver on day of discharge [DC] at facility and at home; medication pickup; transportation of client to home [if medically appropriate]; review of discharge instructions with Care Manager [with intervention if needed]; collection of needed physical therapy [PT], occupational therapy [OT] and/or speech therapy [ST] exercises; advocacy by Care Manager; medication setup in home; answers to clinical questions)

Home safety evaluation and arrangement of durable medical equipment (DME)

Referrals and coordination of all services (skilled home care, non-skilled home care, durable medical equipment, counseling, MD, rehab, dietitian, housing, legal, financial services)

Family consultation and mediation

Interview of caregiver companies with an overseeing of caregiver hiring with appropriate number of hours; education for caregiver (non-medical home care)

Advocacy at rehab/hospital and assistance to discharge (DC) home safely

Collaboration with discharge planner/community case manager, nurses, PT, OT, ST, MDs for care coordination

Documentation of health history/medication list for MDs

Provision of community resources and setup of Emergency Response System (e.g. Lifeline)

Provision of hands-on nursing care at home (e.g. wound care, gastrostomy tube feedings, head-to-toe assessment, notifications to MDs of significant findings to obtain orders)


Crisis Management

24/7 on-call availability

Assistance for out-of-town families with medical emergencies

Advocacy at hospital, rehabilitation center, independent living, assisted living, memory care community, nursing home or at home

Guardianship assistance

Clinical recommendations/oversight

Crisis intervention, support and recommendations

Prevention of re-admission to hospital (Collaborative Care Program)

Read more about crisis consultations and crisis management.


Alzheimer's / Dementia Expertise

specialists in alzheimer's/dementia

Evaluation and education on Healthcare Power of Attorney and Financial Power of Attorney


Housing Options

Assistance with assessing senior housing placement and relocations

Recommendations for services to downsize items and enlist movers

Tours of residential communities (independent living, assisted living, supportive living, nursing homes and memory care communities)


MONEY MANAGEMENT

Evaluation of income level for entitled community resources/support

Application for disability

Assistance with and appeals of Explanation of Benefits (EOB)

Assistance with bill pay

Public aid application and filing with appropriate fiscal documentation

Review of long term care insurance for benefits, opening of claims, coordination with assessment RN to explore ways to maximize benefits

Coordination with CPAs, trustees, financial advisors, etc. 


Medication Management

Medication evaluation and collaboration with MD to make adjustments

Assistance with Medicare Part D

Medication setup and management

Evaluation of cost-effective strategies for healthcare needs/medications


PREVENTION OF HOSPITALIZATION / RE-ADMISSION

Monthly monitoring (1 hour visit once per week) to assist with vitals, medication setup, visits to MD appointments, mediation with family, MMSE (Mini-Mental-State Exam); coordination with caregiver agency staff to ensure family and caregiver are aligned with Care Plan, etc.

Clinical recommendations/oversight by RN, social worker and/or a healthcare advocate

Coordination/communication with physicians, family members and specialists

Advocacy at MD appointments

Referrals to services for client's ongoing needs (skilled home care, non-skilled home care, durable medical equipment, counseling, MD, rehab, dietitian, housing, legal, financial services)

Documentation of health history/medication list for MDs

Nursing care (wound care; gastrostomy tube feedings; head-to-toe assessment; notifications to MDs regarding significant findings and to obtain orders; last-minute home visits if client isn't feeling well)

Coordination of all home care services

Counseling

Evaluation for and arrangement of durable medical equipment

Liaison to long-distance families

Provision of community resources and setup of Emergency Response System (e.g. Lifeline)

Assistance with personal errands

Read more about ongoing care management.


Counseling

Family consultation and mediation

Crisis intervention and support


Guardianship