We can receive requests for service directly from clients. Usually referrals come from client's families, attorneys, physicians, trust officers, hospital social workers and others in a position to identify significant changes in the client's circumstances and capabilities and a need for professional case management help.
Services we can provide range from a one time consultation or intervention in a crisis, or they may involve the development of a comprehensive plan of care and an established relationship that is ongoing. You may choose to take our advice and plan and implement it on your own. Alternatively we can implement, monitor and adjust the client's plan, while keeping you actively involved and informed.
What We Do
Conduct a detailed initial in home assessment focused on the client's physical, mental, emotional, environmental, social needs, social supports and resources. This assessment serves as the basis for making our recommendations and a plan of action.
Develop an individual comprehensive plan of care that enables the client to live as independently as possible in the least restrictive setting. Our goal is to always maintain the client's dignity, actively involve them in decision making, and to support their unique preferences, values and wishes.
Establish and coordinate in home and community based services including but not limited to securing and providing oversight of caregiver, meal delivery, household management, transportation to business and personal appointments, rehab and medical care.
- Provide ongoing monitoring once the in home services are fully established and make adjustments as circumstances change.
- Communicate at regular intervals with family members by phone, e-mail, or in person to better coordinate everyone's efforts and provide emotional support.
- Identify alternative residential placement options including senior congregate living, assisted living and nursing facilities when living at home is no longer a good option. We can coordinate the move to provide a smooth transition and provide regular or periodic follow-up to assure that the client's needs continue to be met.
- Refer to and coordinate with other professionals such as elder law attorneys and trust officers, financial managers and physicians.
- Act as a patient medical advocate. We can help you navigate the often complex health care system, communicate with physicians, clarify treatment options, and understand the choices involved in making health care surrogate and living will decisions. We can assist with the appeal of an insurance denial and help you understand Medicare supplement plan and Pat D drug coverage choices.
- Secure government benefits for which the client is eligible.
- Educate clients and families about their rights, options, responsibilities, and potential consequences to enable informed personal and medical decision making.
- Intervene in a crisis where unexpected events require immediate action. These situations usually involve acute medical or mental health problems.
- We try to be available and maintain on call coverage for established clients with whom we have an ongoing relationship. We work in a team environment and are familiar with each client's circumstances.
- Establish a liaison with hospice care agencies for clients who are or become terminally ill.
- Serve as court appointed guardians in conjunction with a court appointed conservator for clients who have difficulty making rational decisions due to confusion, disorientation and/or memory loss. We consider this in a limited number of cases when a professional guardian is the only feasible alternative.
Fees for case management are on a private pay basis. The costs for our services are agreed upon in advance in the terms of our service agreement. Clients will be billed monthly unless other arrangements are made. Fees are not reimbursed by Medicare or Medicaid.
In some circumstances long term care policies will cover case management if certain conditions are met. We can review your policy and contact the company to make these arrangements for you if appropriate.