Services

Initial Contact

Assessment

Ongoing

Identify the

Client’s or Family’s

Concerns and Needs

Our first conversation would be a discussion via phone (or email) with the focus on the initial concerns that prompted the client to explore care management services. We discuss together what types of assistance the Care Manager can provide, and which steps should be taken. Also, the fee schedule for these services would be discussed and those are as individual as the plan of care.

Assessment Consultation
to Establish Goals and Care Plan

This is in person and the structure would be dependent on individual needs.
The assessment could include any of the following:

Client safety at home

Need for Life Line
Assess physical barriers
Safety equipment, shower chair, walkers,

Need for in-home services to maintain quality of life

Home Health Nurses, Physical / occupational therapy
Caregiver services, housekeeping, errands, meals, transportation

Provide options for alternate living situations

Assisted Living, Personal Care Homes, Rehabilitation Facilities

Assess need for medical monitoring/ongoing access to medical appointments

Monitor prescription medications
Follow up physician/dental/therapy appointments
Advocacy with medical professionals / keep family informed

Long term planning with family members

Assist family with planning for change in medical/physical needs

Referral to legal, community, federal or state resources

Elder Care Attorneys, Veterans Administration
Documents: MPOA, DPOA, OOH DNR, Advanced Directives

Evaluate Spiritual / Emotional / Social needs

Implement and Monitor
Care Plan

•   Build a relationship of trust with the client and to provide support and reassurances as life changes and living adjustments are made

•   Implement and monitor plan of care; recommending adjustments as needed

•   Provide peace of mind to family members with frequent communications

•   Assist with ongoing medical appointments and medical follow-up

•   Provide support and advocacy for clients living in facilities in the community

•   Assist the family or client as needs change and as additional decisions are needed to insure the client’s safety and well-being.

Disclaimer
The Care Manager (CM) provides supportive relationships, assessments, resource utilization and oversight; but does not make decisions for the client or family. Medical issues should be diagnosed and treatment by a licensed medical professional and 911 should be called for emergency situations. Legally binding agreements should be confirmed or processed through an appropriate qualified legal representative.