Helping clients manage……………

• Care Navigation & Coordination

• Care plan development and goal settings

• Coordination of provider appointments, labs, imaging

• Discharge planning support

• Referral coordination to community and social services

• Health system navigation (Medicare, Medicaid, VA)

• Needs assessments for placement (ILF, ALF, SNF, Memory Care)

• Functional & mobility evaluations

• SDOH (Social Determinants of Health) screenings

• Risk assessments (falls, medication, psychosocial)

• Home safety evaluations

• Financial risk screening (non-financial advising)

• Pre-placement assessments for senior housing

• Facility vetting and tour coordination

• Transition planning from across the health care continuum.

• Communication with family decision-makers

• Move-in support services (coordination support with transitioning in to LTC etc.)

• Symptom tracking and chronic disease management education

• Medication reconciliation and education

• Communication with providers and families

• Monitoring of compliance with treatment plans

• Coaching for self-management

• Family caregiver training

• In-home caregiver coaching

• Health literacy support (diagnosis, medication, insurance)

• Fall prevention or chronic condition workshops

• Support group facilitation

• Senior Expo’s and Seminars

• Health advocacy (attending appointments as support, (by request only)

• Family updates and care plan briefings

• Advance directive and goals of care preference discussions

• End-of-life planning support

• Wellness check-ins and status monitoring