Assessment

A care manager assists you in making decisions regarding short and long-term planning care options after visiting with the client and family in his or her current living environment. In the initial assessment we look at the following areas:

• Family/Support - Assessment of the natural support system already in place.
• Housing - Assessment of risk/safety issues in the home setting or residential care environment. Assess for durable medical equipment needs and safety changes in kitchen and bathroom.
• Financial/Legal - Assessment of client's financial status. Education/Information on Durable Power of Attorney for Health Care Form. Provide Long Term Planning Counseling for conserving resources while maintaining client in least restrictive setting. Referrals provided as needed to Estate Planner Attorneys, Financial Advisors, CPA's or Professional Fiduciaries.
• Assessment of medication compliance.
• Evaluation of mobility-safety in the home or residential care setting.
• Assess diet and cooking safety.
• Health Care Insurance - Assessment of health insurance and health care delivery system in place.
• Mental Health Status - Assessment for signs of depression or other mental health issues. Referrals as needed to psychologists, psychiatrists or social workers.
• Cognitive Status - Assessment for signs of Dementia on all clients. If requested provide Mini-Mental Status Exam. Referrals as needed to Neurologists, Neuropsychologists and other Diagnostic Programs for Dementia.
• Assess for attendant care needs. Evaluate for minimum amount of attendant care requirements for client safety.
• Assess for transportation needs.

Individual Care Plan

We set up an Individual Care Plan that includes:

• Outline of services needed.
• Recommendation on level of placement for client.
• Home care services and attendant care services.
• Referrals to other specialists such as attorneys, geriatric professionals, attendant care agencies, home-delivered meal programs, and emergency response systems.
• Intervention strategies to help families with difficult issues related to client's medical and psychosocial status.

Placement

A Case Manager

• Visits with the client in his or her current living environment to provide assessment of their level of care needs.
• Contacts appropriate agencies for evaluation and discussion on client.
• Finalizes placement including setting up a care plan that will estimate care to meet the client's increasing needs in the future.

Ongoing Support

After the initial assessment is complete, ongoing support may include:

• Consulting with physicians, specialists, and/or psychiatrists. Ongoing referrals to community agencies.
• Working toward accelerating quality health care delivery to clients with medical needs.
• Monitoring of individual care plan including adjustments as client's needs increase or decrease.
• Ongoing facilitation and negotiation with service agencies.