Specialized Assessments & Care Plans  

• Preferences, Goals, and Achievement Plan

• Physical and medical record review

• Dementia, Delirium, Depression

• Disease Specific Plans

• Mental Health Issues

• Loneliness/Isolation

• Grief and Loss

• End of Life

• Cost Containment and Resources

• Balancing Support Systems and Family

• Comprehensive Assessment with specific Life Plan involving all items listed above

Health Management   

• Planning and Monitoring Balanced Diet

• Medication management/ evaluation

• Coordination of health related tests and     appointments; implement results

• Coordination and oversight of outside supportive services

• Regular RN visits to determine status

• Health education and care pathways for specific disease or chronic illnesses; implement and monitor

• Procurement of adaptive equipment and/or supplies

Transitions

• Plan for and assist with return home from a hospitalization, emergency room visit, or rehabilitation center

• Assist with all aspects of moving from a residence to an alternative living arrangement

• Relocation to another area

Caregiver Locator  

• Pre-qualify caregivers for clients

• Help client/family hire caregiver privately

• Provide care plan to meet client needs

• Monitor care provided by caregivers

• Keep family informed

• Help replace caregiver, if necessary.

Monitor Facility-Based /Home-Based Care  

• Visit client at the facility or home

• Review care through staff and client interviews, record review, and observation

•  Assess for change in condition/ health status

• Make recommendations, if warranted

• Determine if facility or caregiver continues to meet the client’s needs

At-Risk Evaluations

• Fall risk

• Home safety and modifications

• Repeated hospitalizations/ER use

• Polypharmacy /medication abuse

• Self neglect, exploitation and/or abuse

• Driving and navigation

• Nutrition and hydration

• Disaster preparedness

Property Monitoring and Maintenance  

• Home and vehicle preventative maintenance and emergency repair

• Monitoring home and pets during owner absence due to health or other issues

• Video/inventory of personal property

• Arranging for home modifications

Budget, Asset & Benefits Oversight 

• Budgeting, bill paying, mail management

• Determining benefits and entitlement; applying; filing insurance

• Organization of essential papers

• Assistance with end of life preparations including advance directives

• Assistance with guardianships

Crises Intervention and Mediation

• Establishing common family goals and shared support; conflict resolution

• Intervention in critical and emergent situations

Daily Support Services (Care Associate)

• Transportation services

• Companionship and encouragement

• Housekeeping, Shopping, Cooking, etc.