case management
Our case managers oversee the integration of assessments from your counselors and caregivers, shaping a comprehensive plan of care that addresses your unique health and social needs to provide a sense of safety and empowerment as your navigate through different phases of health
how our case managers help you on your journey...
+ - Establish care with medical providers, including primary care and specialty care ​- Manage medical appointments and facilitate communication amongst various providers to ensure patient-centered care, mitigating duplicated or contraindicated services - Conduct a comprehensive evaluation of acute and chronic medical and psychiatric disorders, health literacy, ADL status, family support - Fulfill referrals for specialty services (such as physical therapy, dialysis, behavioral health) and aide in acquisition of durable medical equipment and supplies - Develop a care plan to achieve short- and long-term health goals related to nutrition, medication therapies, mental health​ - Assess for psychosocial concerns such as abuse, neglect, food insecurity and refer to appropriate organizations for ongoing support
+ - Assist with application for benefits, programs, or grants to aid in facilitating access to medical and social services services - Compare and assist with selecting Medicare Advantage Plans and assist with enrollment in state programs, such as Medicare Savings Plans and Long-Term Care Medicaid​ - Complete state assistance programs (SNAP, AND, SSDI, SSI) - Provide assistace with medical bill management, payment plans, and understanding coverage options
+ - Manage and initiate referrals to different levels of care - Assist in locating placement options for memory care, ALF, nursing home, group home, and host homes - Create a personalized resources catalog create quick access to organizations and agencies who can address current and potential future needs - Facilitate transitions to/from one care setting to another, including hospitals, LTACHs, rehabilitation centers, acute rehabs, assisted living facility, nursing facility, adult day programs, and group homes - Participate in care conferences with providers of residential settings to ensure smooth transition to the next level of care - Complete applications for group homes, facilitate interviews
+ ​ ADVANCED CARE PLANNING AND DECISION-MAKING: - Engage in ongoing therapeutic conversations surrounding goals of care and end of life - Document wishes surrounding end-of-life and artificial means of survival - Facilitate appointment of a guardian or conservator through court petition - Provide education on and create advanced directives including: Medical / Durable Power-of-Attorney, Medical Orders for Scope of Treatment, CPR Directive​s