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Monitoring and Coordination of Care

If requested by the client/family, our Care Management Team can monitor the implementation of the Care Plan. If monitoring is put in place, the Plan is reviewed monthly, or more frequently, with the client. These contacts can be by telephone, in the doctor’s office, at the hospital, or in the client’s home. The frequency of monitoring will vary according to each person’s needs and can include accompanying the client to doctors’ appointments and other activities.

Solutions begin with a phone call or email

To help coordinate complex care, our Team provides the liaison between the client, family and the other care providers, such as, hospitals, medical specialists, rehabilitation therapists, and home care providers. One of the team’s highest priorities is to coordinate and supervise care providers, as well as manage transitions to other facilities, such as assisted living or skilled nursing. The Care Management Team functions as the primary communicator among all care providers and supervises home care providers to ensure proper care is delivered according to the Care Plan. The Team can also help families determine the best living arrangements for their loved ones and facilitate any transitions for the client.

Peace of mind

Our Care Management Team is available for crisis intervention and management, such as emergency hospitalizations or sudden changes in health status. Our Care Manager can meet your loved one at the hospital or doctor’s office to provide information to health care providers and a familiar face to your loved one.