Medical Care Coordination

Our medical care coordination services include:

• Nurse wellness visits
• Management of a clear and comprehensive med list
• Coordination of care between specialists and PCP
• Ensuring appropriate and timely follow up with all specialists and maintaining regular preventative care schedules
• Speaking with physicians to provide advocacy and follow up with questions or concerns
• Developing a clear medical treatment plan and goals, educating and coordinating with physicians and specialists to adjust the treatment plan and goals as needed
• Management of chronic disease diagnosis and educating client, family and care- givers to provide better care and management of the disease
• Coordination of other providers and resources: Home health care, Hospice, therapy in-home, Concierge MDs, In home MDs, medical equipment needs, etc.

General Client/Care Coordination and Management

Assessing our clients’ needs within the comfort of their homes is a key aspect of formulating a comprehensive plan that addresses their safety, care, and supervision. We take into account their unique goals, needs, and preferences to ensure a personalized approach. Collaborating closely with clients and their families, we work together to establish explicit care management goals. This collaboration is vital in ensuring alignment among all stakeholders and fostering open dialogue to explore various support options.

Our commitment extends to introducing necessary resources into the home environment, enhancing client safety, and promoting independence. We actively assist in the identification and exploration of suitable communities for potential relocation when needed. We coordinate seamlessly with various healthcare services post-hospitalization, including home health care, hospice, therapy, and outpatient clinics, addressing specific medical appointments such as dialysis, PT/INR, and chemo/radiation.

Regular reassessments are conducted in response to changes in the client’s condition or the emergence of new diagnoses. We take the time to understand the client’s daily routine, facilitating the development of a clear care plan and task list.

In overseeing caregiver responsibilities, we ensure that tasks are executed in a professional, safe, and compassionate manner. We establish transparent expectations regarding the scope of a caregiver’s role, whether they are an independent contractor or an employee of our company.

Identifying areas for caregiver training is a priority, and we locate relevant resources within the home to achieve optimal outcomes. Our company is dedicated to providing comprehensive and personalized care management services to meet the diverse needs of our clients and their families.

We take the time to understand your goals, care needs, short term and long term priorities. If at any time, home is not the right decision and place for your or your loved ones, we will assist with the transition to the appropriate community placement.


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