Services family members; provide trusted referrals within the

Services include:Geriatric assessment to determine care and needs, then develop and implement the care plan. Ongoing care management, reassessing the plan as abilities and needs change Obtain and oversee home health agencies, social and rehabilitation services. Communicate and coordinate with other professionals, service providers and family members; provide trusted referrals within the community Collect all medical records, coordinate medical appointments, confer with and facilitate communication among all the physicians, caregivers, home health agencies and hospitals, nursing homes, assisted living and /or rehabilitation facility. Research and assist in transitions from home to assisted living, senior communities and skilled nursing facilities, where we will continue to monitor and oversee care. When hospitalized our certified patient advocates guide the patient through the healthcare system, ensuring the diagnosis, prognosis and treatment options are clearly understood.

Make sure all the caregivers are on the same page, treating the whole person, not just the doctor’s specialty. Research illness and disease, ensuring you get the education needed so true “informed consent” can be given.Evaluate discharge plan and refer to appropriate rehabilitation facility. Oversee care plan at rehabilitation facility Evaluate home and arrange for home care, nursing, therapist, aides, equipment, then manage and oversee the care.

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