Care Management

alca infographicCare management is a broad term for a range of services that cover nearly every aspect of a senior’s life. At HealthSense, we understand that in order to provide such a comprehensive role in our clients’ lives, we need to spend time with them, see where they live and who they rely on for care. Our process begins with a thorough assessment, which covers a client’s:

  • Physical health
  • Cognitive health including screening for dementia
  • Mental health including screening for depression
  • A thorough medication review to identify accuracy, compliance, tolerance and whether it is advisable to implement a structured medication management system
  • Functional assessment of abilities to perform basic activities of daily living, such as dressing, bathing, grooming, etc.
  • Identifying common geriatric risk factors such as frequent falls or nutritional vulnerabilities
  • Environment and safety review of the home
  • Support, resources and care systems available

After we’ve completed our evaluation, we’ll develop a comprehensive Plan of Care, which will recommend specific steps to optimize health and promote independence and enjoyment, while balancing safety and health needs. This care plan may include:

  • Specific recommendations for both short and long-term health care planning, such as physician referrals, home care options, rehabilitation, complex care needs, living options, palliative care and end-of-life care needs
  • Coordinating and facilitating Advance Directive planning such as health care proxies, Living Wills, and Powers of Attorney and educating clients on specific directives such as Non-Hospital Do Not Resuscitate (DNR) and Medical Order for Life Sustaining Treatment (MOLST) forms
  • Recommendations for home safety and comfort improvements for those who want to “age in place”
  • Providing guidance on appropriate local resources that can help with specific issues

We also can provide assistance in implementing and monitoring the care plan, which may include:

  • Accompanying clients to medical appointments and advocating on their behalf
  • Assisting in assembling a competent and compassionate team of home care professionals
  • Ongoing re-evaluation of the care plan, to ensure that it is achieving its goals
  • Coordinating and connecting the client with other resources, including support groups, educational literature and websites, and health care specialists
  • Acting as a liaison between all of a client’s health care providers to help ensure everyone is working cohesively with a unified purpose and knows what the other is doing
  • Implementing and overseeing medication management systems
  • Providing crisis intervention and triage in the case of an emergency