Planning Assessment:
Conduct comprehensive medical, functional, cognitive, psycho-social, financial and safety assessments to determine the level of care and unmet needs.
Tailored Plan of Action:
Develop an individualized plan for care and needed resources with input from the client, family and community professionals.
Care Coordination and Advocacy:
- Assist client/family to hire in-home caregivers and monitor services rendered
- Accompany client on medical appointments to insure timely, accurate and thorough exchange of information
- Coordinate medical instructions of multiple physicians and specialists to ensure correct follow-through
- Provide medication review and management
- Provide friendly visits and telephone reminders/reassurances, as needed
- Monitor whether all care and services delivered are reliable, compassionate and of high quality
- Offer crises management
Financial Checkup:
- Provide direct or referred resources for daily money management including timely bill payments, bank statement reconciliation, health insurance claims, and tax preparation
- Complete paperwork necessary to apply for state/federal benefits and local cost-saving programs
- Assist with inventory of important documents needed for applications and legal issues
Life Transitions:
- Insure safe transfer to/from hospital, rehabilitation facilities and home including medication reconciliation, follow-up medical appointments, and needed supplies and equipment
- Relocate from home to alternative living arrangements such as assisted living
- Discuss with client and family end-of-life issues including advance directives, palliative and hospice care
Family Consultation:
- Hold family meetings to help with complex care decisions
- Mediate family differences of opinion in care of a parent
- Provide short-term respite monitoring for a parent during a caregiver’s business trips, family vacations or needed breaks
- Act as liaison and advocate for local or out-of-state family to provide alerts if their loved one is not safe and well
- Keep lines of communication open and maintain regular contact