How we do it
Pinpoint the client's unmet needs
Through an initial meeting and discussion of the client’s care needs, we will develop a written needs assessment report with our professional recommendations. We will review primary areas of need including the client’s past and current functional status, medical history, general legal and financial status, emotional supports, social history and religious preferences, and the client’s stated goals. We'll incorporate cognitive, functional, and psychological assessments where appropriate and pertinent to the client.
Collaborate on developing a plan of care
We will schedule an initial review of the written report with the client and their designated support team. From there we will discuss our recommendations and collaborate on determining priorities and establishing a plan of care. By incorporating the client’s financial and functional status and care priorities, we'll create a baseline plan to build on as the client goes through life's transitions.
Coordinate & Monitor client's condition
For ongoing care management services, we'll manage the details for the client and attend appointments as their advocate. We'll follow up with the client’s medical team, delegate tasks to skilled professionals where necessary, and hold them accountable to always consider the client’s best interest. In collaboration with the client's professional team, we will implement a plan of care. We’ll simplify the details, while actively solving problems as they develop and proactively planning for future obstacles.
Keep care team connected and updated
We will send regular updates to the client’s authorized persons and loved ones, facilitate ongoing communication among their medical team, and maintain documentation and record of changes in care. We provide family education where needed and aim to empower the care team to meet care goals while following the client’s stated wishes. By preparing a backup plan, we can proactively address and update the client’s care team to meet challenges head on and facilitate excellent quality of care.
a•bridge: Aging Life Care Management applies the eight knowledge areas to their expertise:
Health & Disability