Sometimes we are called upon by local families for a professional assessment only, to assist the families to make decisions regarding their loved one's care. Often, the families will want us to help them to arrange and monitor these services if they do not have the time or resources to do this themselves. We can also counsel clients to help them adjust to changes in their level of function or living situation. If families do not live in the area, we are frequently called upon to manage complete care of the client, monitoring and changing our plan of care as their needs change.
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Our care management service is the brick on which our practice is built. Based on our initial assessment of the client's needs, we formulate a plan of care. We conference with the families to discuss how these needs can be met, offering all existing alternatives. Once that is determined, we will put our plan into action and then monitor the client. This plan is continuously updated as the client's needs change. back to top
Our initial assessment includes the evaluation of all aspects that influence a person's safety and quality of life. We assess the client's mental ability, psychological status, physical abilities (to determine how their activities of daily living can be performed), medical conditions, financial situation (for short and long-term planning), legal situation (to ensure that all proper documentation has been prepared), and their social and religious situation (to identify needs that may not always be considered). back to top
Our geriatric care managers are on call 24 hours a day/7 days a week. One of our most valuable services, especially for out-of-town families, is the ability to respond to emergency situations. The client always has someone to call, and if it is necessary for the client to seek immediate medical attention, we are available to meet them at the emergency room to ensure that the attending physician has all of the medical history and current medications, as well as provide the hospital with the proper family contact information. back to top
This is the strength of our geriatric care managers that are nurses. We are able to follow through on medication changes, observe for untoward reactions, give special instruction to private caregivers, and contact physicians if medications need to be revised. Our social workers, though having extensive knowledge of medications, will review all medications with an RN when needed, and also when we hold our weekly case conferences. back to top
We often arrange for private caregivers, and will evaluate the care of our clients on each visit to their home. We will instruct the caregiver if needed to improve their care, make suggestions, and constantly assess if the level of care is adequate. These private caregivers do call us for advice and do inform us of any changes or concerns. back to top
Being familiar with the resources in the community, we can offer suggestions to assist families with their care, resources that they may not have been aware of. Social workers in hospitals and nursing homes do not always have the time to refer their patients to all of the resources that can help. back to top
This is one of our most important functions. We are the eyes for families that live at a distance. We are also the educators that can explain to families why a certain medical regime is being followed. We inform the families of changes and look to them for decisions regarding the care of their loved one. back to top
The Centers for Disease Control and Prevention has begun a campaign to educate the public on Fall Prevention. Read an article from the August 12, 2008 issue of The New York Times on our Articles page discussing recent research on falls among the elderly. Our home safety assessment includes making the home safer to decrease the likelihood of falls, and our clients are assessed for fall risk. The effects of a fall for the elderly can be devastating. In addition, we look at other aspects of the home that can be dangerous for the elderly. back to top
When we perform a financial assessment, we examine what resources are available for the present care of our client, and also what will be available in the future as far as anticipated needs are concerned. We often tap into resources that are unfamiliar to families. back to top
At the completion of our initial assessment, we will be able to discuss appropriate housing for our clients. We are able to keep nursing home candidates in their homes, as long as they have the funds to pay for private care. All of their needs can be met at home, and they will benefit from getting one-to-one attention rather than to be placed in a nursing home. We also can assist in finding the appropriate facility if the client cannot remain in his home and can monitor all care given there. back to top
Our geriatric care managers are present at doctor visits, and visit clients in assisted living facilities and nursing homes. We can evaluate the care given, and at the same time hold down costs by avoiding duplication of services. We speak up for our clients when they are unable to do so. back to top
The owner has two therapy dogs that she takes to nursing homes, and will make her dogs available to selected clients at no charge for Pet-Assisted Therapy. This therapy is documented to have a positive effect on dog-loving clients, and can be especially beneficial to someone who has become isolated at home. Click here to view more on Pet Therapy. back to top
Our geriatric care managers are available to assist clients with their bills. This is especially helpful for people who are visually impaired, hard of hearing, or just need assistance to decipher complicated bills. back to top
Many families that live at a distance choose to care for their loved one, but it becomes necessary to move them closer to their home. We can assist in this process by counseling the client, preparing for the move, packing, shipping items, and even help in the sale of their house or condo.
In addition, we also assist with moves into an assisted living facility or a nursing home. This is a tremendous change for the client, and can be eased by having a care manager counsel the client to help her through these changes. It typically takes six months time for an elderly person to adjust to the move from home into a facility. back to top
Once again, we act as a family member would in caring for our clients. Many times we are called upon for various functions. Home maintenance is one that is imperative when it comes to the safety of the client in the home.