Assessment
The work begins with a thorough assessment, usually done in the home. A care manager will visit the individual in need of assistance and consider all areas of functioning during the interview. Most of our clients are aging in place and want to stay independent in their own homes as long as possible. We use a strengths-based perspective to highlight what is working and how they have been able to live well with aging until now. We will consider their physical, cognitive, social/emotional and medical status as well as community resources, family and other supports. We will also review finances, benefits and advance care planning. Some questions we consider during the initial interview include:
- How are they staying independent in their homes?
- Do they have or need companion care or home care?
- Are they taking medications?
- If so, how are they being managed?
- Do they need to make home modifications?
- Are they living with memory challenges?
- Are primary care providers and specialists providing the best possible care?
- Are they making medical decisions on their own?
- What are their passions, hobbies and interests?
- Are they able to purse these passions and interests at this time?
- Are there arrangements we can make to enhance their quality of life?
Goals of Care
Once an assessment is complete, we have a comprehensive understanding of what is needed and devise an individualized plan of care based on our findings. This is where we build solutions by harnessing our knowledge and expertise to navigate the complexities of the healthcare system, community services and local resources. We make referrals and advocate tirelessly for our clients to get what they need. Some things we do may include but are not limited to:
- Find excellent caregivers who provide care that meets the unique needs of the individual
- Identify and procure professionals needed including doctors, physical/vestibular therapists, personal trainers, nutritionists, pedicurists, memoir writers, creative art therapists, bookkeepers, Daily Money Managers, attorneys and more
- Coordinate out of the house and in-home appointments and services
- Keep calendars up to date
- Accompany clients to appointments
- Obtain pertinent medical records and share with appropriate providers
- Communicate with family members regularly
- Serve as a liaison between medical providers and families
- Arrange home-cooked meals that meet medical/nutritional requirements
- Arrange cultural outings to see museums, concerts, theater, etc.
- Assist with bill paying and other administrative tasks as needed
- Ensure that the home environment is tidy; retain and/or supervise cleaning people
- Help organize home, clear clutter, and assist with projects
- Assist in memoir writing: typing, computer work and research
- Explain home shares and explore pros/cons
- Conduct search for roommates to share living space in exchange for support in the home
- Anticipate potential problems and find ways to prevent them