Senior Help

GERIATRIC CARE MANAGEMENT

Consultation/Information and Referral: One to one consultation providing problem assessment, education, information, resources and referrals.  Screening for risk factors: depression, mental status/capacity, nutrition, medication adherence, falls, abuse, home safety.

Comprehensive Geriatric Assessment: Psycho-social evaluation, review of all medical and pharmacy information, confer with client’s physician, assess functional activities of daily living, review legal status/advanced directives, long term planning and financial status as it pertains to meeting future care needs.  Make recommendations in each category assessed.

Care Planning: Identification, linkage, set-up and coordination of appropriate resources and services tailored to meet the client’s needs.  Care plans are set up and frequently reviewed and services reassessed to be sure they continue to meet the client’s needs and address any changes the client is experiencing.

Facilitation of Communication of the client’s status and needs to family (particularly out of town caregivers), support system, physicians and other professionals involved in the client’s care. 

Home Care: assess client’s need for care at home.  Determine level of care and amount of care needed.  Identify potential service providers and assist client or caregiver in hiring home care services. Provide periodic review of homecare needs and assist client and caregiver with monitoring services. (There is a significant difference between skilled home care services and non-medical homecare services.)

Change of Residence/Move to A Senior Housing Community:  Assess client’s care needs and determine the appropriate level of care and the cost of that care.  Provide information and recommendations for facilities that meet the level of care criteria.  These may include independent living, assisted living, dementia care or skilled nursing facility.

Community Social Services: Identification of social services, adult day health care programs, caregiver respite and support programs, home delivered meals, housekeeping, home maintenance and safety programs, educational and recreational programs that may improve client’s quality of life.

Advance Directives, Living Will, Power of Attorney: Review elder’s legal needs and refer to specialists in elder law, estate planning, fiduciary and trustee services as needed.  Provide guidance and assist in accessing Veteran’s benefits and long term care funding including Medicaid planning for those who cannot pay for long- term care.