Depending on the needs of the older adult, the care plan may include any of the following:

     - Assistance in applying for benefits

     - Assistance with routine needs such as procuring benefits, paying bills, linking to social and recreational opportunities, coordinating   

       transportation, and accessing other community support services

     - Family communication providing updates

     - Facilitation/Mediation of family meetings

     - Crisis intervention

     - Healthcare coordination including organizing doctor appointments and caregiver services

     - Medication review for possible drug-interaction risks

     - Cognitive enhancement, brain stimulation and enrichment activities

     - Option evaluation and healthy transition if alternative housing becomes necessary

     - Assistance with End of Life documents​ 

Coordination of Care

The evaluation is designed to optimize an individual's ability to enjoy better health,  avoid risks, improve self-care and to improve overall quality of life.

    - Do you feel it is time for an evaluation of physical and/or cognitive abilities?
    - Do you feel your loved one is safe and making good decisions?
    - Are they able to maintain their financial responsibilities?
    - Is your loved one able to manage their medications as prescribed?
    - Do they have difficulty making decisions or seek constant reassurance?
    - Are they overwhelmed with their inability to manage activities of daily living?
    - Is it time to develop support systems to utilize their personal strengths?

Daily Activities and Errands

Services

Depending on the needs of the older adult, the care plan may include any of the following:
    - Bill Paying Assistance
    - Errand and Transportation Service
    - Accompaniment to Medical Appointments
    - Medication and health care coordination
    - Hospital discharge planning and assistance ​

Assessment

Care Plan

​A client's customized Plan of Care addresses all concerns and recommends services to assist in meeting the client's wants and needs as identified in the assessment. The Care Plan not only suggests specific interventions and recommendations but also indicates how the Care Manager can assist with implementing the plan and provide ongoing assistance and support. 


A Care Plan may include:
    - Solutions and /or assistance for concerns and issues such as capabilities and functions.
    - Needed medical equipment, home safety modifications and adaptation assistance.
    - Arranging/overseeing in-home care, medical monitoring, compliance with medications and vital signs.
    - Recommendations for support groups, referrals, socialization opportunities and cost effective options.
    - Ongoing/monitoring plans for the future to reduce hospitalizations, doctor's appointments and ER visits. 

Choices Care Management

Heart

Geriatric Care Management