Care coordination is a compassionate person-centered process that involves the thoughtful organization of activities to achieve safer and more effective care for seniors. This means that the elderly person's needs and preferences are known ahead of time and communicated at the right time to the right people. The goal of care coordination is to be a preventative progression of how to age well and offer peace of mind. While the goal of the care plan is to avoid a crisis situation, a care coordinator steps in at a time of crisis to help a client and/or their family navigate options and help implement solutions.
At Schluter & Hughes Law Firm, PLLC we have dedicated care coordinators who help seniors and their families navigate the maze of aging services that make up the continuum of care. Our Care Coordinators are problem solvers and services range from education, service coordination, recommending and attending doctor visits, living transitions, and providing in-home safety suggestions.
Continuum LifePlan: What Your Patient Advocate Should Know
- Initial assessment of current care needs in clients' residential setting
- Assessment and personalized care plan creation
- Access to online centralized medical information and care plan
- Access to care coordination team including registered nurse/geriatric consultant at an hourly rate as the need may arise
Annual Review of the Continuum LifePlan
- Assess for optimal care services based on health fluctuations as evidenced by physician care, hospitalizations, alternate residential care settings, rehabilitation, altered mental status, altered mobility, medication changes, or other pertinent issues
- Reassess and update the care plan to meet current healthcare needs
Customized navigation of care needs and advocacy to improve quality of life of the individual or couple in the home or senior living community.
- Care plan implementation
- Arrange and monitor home health or facility services
- Coordinate medical appointments and self-care appointments
- Routine wellness checks with client's needs assessed by a Care Coordinator
- Review financial, legal, or medical issues and arrange referrals as needed
- Attend doctor appointments as requested and advocate for the client
- Act as a liaison for patient advocates needing additional support, monitoring, and oversight
- Assist with moving a client to and from a senior living community or care facility
- Hospital visits to assist in discharge planning and necessary rehab services
All services billed at an hourly rate. Quarterly or Monthly Oversight plans may be available upon request. NOTE: It is the client's responsibility to make known any pertinent healthcare changes. The care plan will be updated on behalf of the client. A printed copy available upon request