The comprehensive assessment is the first step in determining the needs of an individual. The Aging Life Care Manager will meet with the client in their current environment; home, facility or hospital, to evaluate the current situation and determine the appropriate needs. This comprehensive assessment may include family, extended family, close friends and other support service representatives. The information obtained is used to develop a customized Plan of Care that best meets the client’s unique situation.
The Care Manager will evaluate the Client’s:
- Physical, Mental, Cognitive & Psychosocial Evaluation to Determine Independence Level & Safety
- Gathering of Medical and Surgical History
- Medication Review
- Nutrition, Sleep, Life Style, & Quality of Life Status
- Home Safety & Fall Prevention Assessment
- Caregiver and Residential Community Profile Assessment
- Advanced Directive / POLST Review
- Professional Recommendations (in-home care, placement options, medical, financial, legal needs)
Plan of Care
A Plan of Care is a road map to meet the client’s needs. It includes recommendations for resources and services to assist in managing a client’s unique situation. The Plan of Care is based on the comprehensive assessment with the focus on helping the client to live at their highest functional level in the least restrictive environment possible.
An Individualized Plan of Care can include the following Recommendations:
- Appropriate Living Environment
- Medical Providers
- Durable Medical Equipment (DME)
- Transportation Services
- Medication Management
- Companion/Caregiver Services
- Home Health Services
- Financial and Legal Professionals
By developing customized care plans tailored to your loved ones need, and setting up services and referrals, Catherine makes sure the plan is instituted and followed so to have positive outcomes. These activities not only help the client, however, also provide much-needed solutions for the spouse, adult child or family member who find themselves in a crisis on how to help their loved ones.
What is Ongoing Care Management?
Once the Plan of Care is completed and recommendations are carried out, you may find that you need your Life Care Manager to oversee and manage ongoing services. If you live out of town or work keeps you busy, who will manage the caregivers in the home to ensure duties are performed and your loved is being cared for appropriately? How will you know your loved one is taking their medications correctly or attending their MD appointments? If your loved one has dementia, how will they remember the details of what their doctor explained? Who will be there in cases of emergency when you cannot?
Ongoing Care Management Services
- Re-Evaluation of Independence Level as Needs Change
- Routine In-Home Visits
- Crisis Intervention (24/7 Availability for Urgent Care or Emergency Room Visits)
- Medication organization (Routinely Filling Weekly Pill Boxes with Prescription Medications)
- Interview, Hire, Train, & Manage In-Home Caregivers
- Liaison with Family Members Providing Counseling & Conflict Resolution
- Counseling for Client Facing New Life Altering Diagnosis/Relocation challenges
- Medical Appointment Scheduling & Coordination
- Taking Client to/from Doctor’s Appointments and Informing Family of Results
- Communication with Third Party Providers i.e. Doctors, Discharge Planners, Long Term Care Co.
- Matching Residential/Assisted Living/Memory Care Communities with Client Needs
- Coordination of Facility Tours & Assistance with Pre-Admission Paperwork
- Assistance in Placement Transition & Coordinating Moving Services
- Facilitating End of Life Care Discussions
- Reviewing Advanced Directives/POLST forms to confirm current wishes are properly stated
- Hospice Coordination and Funeral Arrangement
- Grief/Loss & Bereavement Counseling
Schedule a Free Consultation Today.
An Aging Life Care Manager is Available 24 Hours a Day, 7 Days a Week.