Ongoing Care Management

Collaborative Care Program

The Collaborative Care Program involves a team approach with a non-medical home care company and a Care Navigators’ Care Manager or Healthcare Advocate to oversee the entire plan of care. The team will ensure the client is transitioned home or to a rehabilitation center safely.  Care Navigators can work with the non-medical home care company of your choice or recommend one. 

Continuous Care

Care Navigators is able to monitor your loved one’s changing healthcare and support needs at home. A client who has been doing well with a part-time caregiver may, with declining health, require more assistance. The Care Manager can evaluate the situation to make professional recommendations in your loved one’s ongoing care.

Personal accompaniment to and from medical appointments may also be provided by a Care Manager. A Care Manager can be present with the client during appointments and in the exam room (if appropriate) to assist the client in better understanding his/her medical needs and relay information to the family.

Ongoing care management includes assistance with day to day tasks that may become difficult for the older adult. This could encompass paying bills, balancing checking accounts, tracking/submitting insurance claims and making/keeping appointments.

Clients who reside in retirement or nursing communities may also benefit from ongoing care management. Care Managers are trained to oversee the care and services provided in these communities. They advocate for the client and provide medical updates to the family. Care Managers can also attend patient care conferences with or without the family, updating the family on outcomes and recommendations.