- Conduct an in-depth Assessment of your loved one’s physical, psychosocial, cognitive and environmental status including fall risk, depression screen and home safety.
- Help prevent the need for hospital visits by observing all changes and report to doctors, health professionals and designated family.
- Intervene immediately to control symptoms and prevent a crisis.
- Reconcile and manage medications; ensure they are taken properly.
- Identify and minimize risks and potential safety issues in the home by removing environmental hazards and make environmental modifications as needed.
- Monitor your loved one’s condition and plan of care, and adjust as needed.
- Support and “coach” caregivers and family members.
- Mediate within families to find resolutions to care needs.
- Help reduce family stress and burden when your loved one requires hospital admission by navigating the system and actively participating in discharge planning and transition between care settings.
- Assist with Long Term Care Planning, by identifying benefits and special products.
- Review legal and financial status and provide direction.
- Advance illness counseling by discussing 5 Wishes and Advance Directives.
- Accompany your loved one to medical appointments and report findings to designated family.
- Decrease care fragmentation by communicating, collaborating and coordinating frequently.
- Aid in placement and relocation assistance.
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