CARE MANAGEMENT SERVICES
Needs Assessment & Care Planning
- We begin by interviewing a new client and that client’s support team including involved family members, decision makers, physicians, social workers, chaplains, residential facility staff and/or caregivers to determine the client’s current needs, capabilities, desires, challenges and opportunities.
- We collaborate with relevant team members to develop a comprehensive written Client Care Plan.
- We regularly review and update this plan with client support teams as appropriate.
Consensus Building and Coaching
- Employing either family meetings or individualized sessions, we help team members and families identify issues of commonality and improve their working relationships, helping them to move beyond conflicts that can hinder support for the client.
- We facilitate the creation of ideas and solutions that can help move the participants past their obstacles.
- We assist with the creation of durable agreements that can preserve successful, supportive relationships among team members and families.
- We oversee the agreed upon plan and monitor it should needs and goals change.
- We facilitate effective communication amongst client and team members, in service of the client’s best interests.
- In this process, we maintain client confidentiality in accordance with HIPAA guidelines, disclosing only information that is necessary and appropriate.
Emotional Health & Well-being
- We monitor client mood/affect and socialization as needed via direct contact, observation of client interactions with others and check-ins with in-home caregivers and/or facility staff.
- We encourage participation and engagement in activities which promote physical and cognitive stimulation to avoid client isolation, loneliness and depression.
- We mediate relationships with clients’ significant others, responding in a timely manner to their questions and concerns in relation to client’s care needs.
- We elicit sharing of client stories through active listening, empathy, and reminiscence therapy, as appropriate.
Physical Health & Well-being
- We manage medical and dental appointments, scheduling, transportation, etc.
- We accompany clients to medical appointments as needed.
- We confer with physicians and other health care professionals to monitor clients’ physical well-being.
- We ensure availability of medications prescribed by client physicians as well as OTC supplements.
- We monitor client health status including eating habits and nutrition, and significant weight changes.
- We evaluate safety and maintenance needs in the client’s living environment.
- We inventory and secure client valuables, such as jewelry and art, as needed.
- We inventory, when necessary and appropriate, a client’s personal property, clothing, shoes and toiletry items, noting client’s preferred styles, colors, sizes, brands.
- We manage client needs for any such personal items, arrange shopping trips.
- We manage all aspects of a client’s move, if necessary, to a more appropriate living situation.
Fiduciary Support Services – As directed by client or designated decision-maker
At times, a fiduciary is already in place and intends to remain in that role. We can employ the following services to help the trustee or other fiduciary carry out their responsibilities:
- We conduct a thorough inventory of assets, asset valuation, and assessment of current financial needs.
- We collaborate with clients and their designated decision-makers to establish a Financial Management Plan.
- We can review existing estate plan documents (e.g. trusts), highlight issues for consideration, and ensure that the financial strategy is consistent with the objectives of the plan. We can also make referrals, if necessary, to legal counsel for potential modification of plan.
- We can advise on distributions to beneficiaries.
- We can consult with a Certified Financial Planner in order to assess a financial plan and develop a long term financial management and investment strategy.
- We can prepare a cash flow analysis and financial statements.
- We help with bill-paying, bookkeeping and budget establishment.
- We process insurance claims.
- We conserve clients’ assets wherever possible while preserving their quality of life.
- We can organize tax records.
- We prepare annual accountings to clients, their beneficiaries, or the court if required.
- We collaborate with and undertake advocacy with financial institutions, pension plans, insurance companies, government agencies.