Care management provides access to the best resources in healthcare, financial planning, housing, and legal issues for individuals who face particular challenges in life. This includes those living with a chronic disease such as Multiple Sclerosis, Parkinson’s, diabetes and dementia; those living with a developmental disability; and those who simply need help navigating their way through the many facets of aging well. Our services consist of four main areas of assistance and expertise.

Assessing the Situation

Care management begins with a comprehensive assessment of the current situation. We meet with you and your loved one to discuss your needs or concerns. An assessment may include a review of how well the individual can carry out the basic activities of daily living, such as bathing, dressing, driving or preparing meals; understanding how the individual spends their day and their quality of life; or analysis of psychological, mental, and social functioning. We also learn more about the person’s history and financial resources, review medical records, and consult with other family members and health care providers as needed.

Developing a Plan

The assessment leads to the development of a care plan. This plan outlines the personalized services that will guide us in optimizing the independence, dignity, and quality of life for the senior or disabled person. The plan includes guidance on how a family caregiver can arrange the necessary services or obtain resources. Depending on the situation, it may include support for staying at home, exploration of care facilities and community support services, recommendations for adaptive equipment, or referrals to psychiatrists or cognitive specialists. Education and emotional support for the client and the family are also incorporated into the plan.

Implementing the Plan

A care manager can continue to work with you to implement the care plan. This may include organizing and coordinating services, educating the family on care, attending medical appointments, advocating for the client’s needs, and/or providing referrals to care services that provide compassionate support. This may mean working with insurance agencies, applying for Medicaid or other benefits, or working with providers to make sure they are utilizing the benefits properly.

Adapting and Revising

Change is inevitable. As part of the aging life care management process, we work to anticipate changes and adapt the care plan accordingly. Reassessment can be a continual process if we remain an active part of your care process, or we can work with you on a periodic basis to discuss what might come next.