Care Management Services

CARE MANAGEMENT

We offer comprehensive, compassionate support for aging adults through expert guidance, advocacy, and seamless coordination of supportive services tailored to each client’s individual needs to ensure safe and consistent care at every stage of aging. Our Care Management process is built on trust, compassion and expertise that typically includes the following:

  • Consultation & Assessment: Our Care Manager connects with the clients and families during an initial phone consultation to begin establishing a trusting relationship. This is followed by a thorough in-person assessment of the client’s health status, functional and cognitive abilities, emotional and social needs, safety and environment, caregiver support and financial and community resources.

  • Customized Care Planning: After the assessment is completed, a care plan is developed specific to the identified needs with recommendations to support the client’s well-being and enhance their quality of life.

  • Ongoing Support & Coordination: Our Care Managers are continuously monitoring the client’s needs and seamlessly coordinating various aspects of daily living. We recognize that urgent needs often arise; therefore, requiring consistent care coordination and oversight of a range of services that offer support when it’s needed the most.

Our involvement doesn’t end here. We can assist beyond the basics with one or more of our Enhanced Care Management Programs. Our goal is to make every aspect of aging manageable whether it’s a chronic condition, a need for relocation assistance or a transitioning from hospital to home. We want to be the Care Managers of choice in navigating the complexities of healthcare while aging gracefully.

The following services may be included but not limited to the care management program the client is enrolled into:

  • Benefits & Eligibility Review

  • Personalized Care Planning

  • Discharge Planning Assistance

  • Medication Management

  • Relocation Assistance

  • Comprehensive Assessments

  • Coordination of Care & Resources

  • Home Care Coordination

  • Chronic Condition Management

  • Advocacy & Support

Enhanced Care Management

  • Chronic Condition Management

    Our Care Managers provide ongoing support for adults, seniors, and individuals with disabilities living with chronic health conditions such as heart disease, diabetes, COPD, dementia, Alzheimer’s, and Parkinson’s. We focus on medication management, appointment coordination, and seamless communication among the client’s care team to ensure their care remains consistent and personalized. By monitoring health changes and advocating for both clients and caregivers, we help the client stay on track with their care plan, prioritizing their health, safety, and quality of life every step of the way.

  • Transitions of Care Management

    We have a Certified Managed Care Nurse on staff with extensive experience with working closely with hospital and extended care facility case managers and social workers, as well as other healthcare providers, to support the transition of care plan to ensure it is medically appropriate, cost-effective and timely. We offer ongoing monitoring and support post-transition, from the hospital to home or a rehab facility, with scheduling follow-up appointments, reviewing and reconciling medications, and coordinating resources.

  • Coordination of Home Care & Community Based Services

    Our team proactively plans and manages every aspect of care from home care and home health, adult day centers, medical appointments and medication management to home-delivered meals, transportation, and community resources; ensuring safety, comfort, and independence at every stage of aging. With us, clients and their families can feel confident that every decision prioritizes our clients’ health, well-being, and quality of life.

  • Advocacy & Support

    Our care managers make sure every person’s needs, rights, and choices are respected and valued. We serve as trusted partners, guiding individuals and families through medical, social, and community systems to find the help they need. We offer emotional support, education, and coordination to make difficult situations easier to manage. Most importantly, we empower clients and their loved ones to make informed decisions and feel confident in their care and quality of life.

Care Management FAQs

What is care management?

Care management is a personalized service that helps individuals and families coordinate and optimize care, especially for those with complex or chronic health conditions. Care managers assess needs, develop personalized care plans, coordinate services, and provide ongoing support to ensure safety, well-being, and the best possible quality of life. Care managers serve as an advocate to ensure ensuring you or your loved one receives the right care at the right time, every step of the way. With care management, you’re never alone in facing health challenges.

How is care management different from home care services?

Home care services focus on providing personal assistance, such as help with daily activities, meal preparation, errands, and light housekeeping. Care management, on the other hand, involves a more comprehensive and ongoing process that includes an assessment, create and adjust your customized care plan, coordinate with doctors, specialists and other healthcare providers, manage medications, and connect you with vital community resources. Care managers also serve as a liaison between clients, families, and caregivers.

Who would benefit from care management services?

Care management is a true lifeline for adult, senior and disabled individuals with complex medical conditions, multiple chronic illnesses, and those who need help navigating healthcare and community resources. It is also valuable for families, especially those living far away, who want expert guidance, local advocacy, and real-time updates to stay connected and confident in their loved one’s care.

How does the care management process work?

A care manager starts with an initial assessment to understand the client’s needs. They then develop a personalized care plan, implement services, and regularly review and update the plan to adapt to changing needs. They also coordinate services and communicates important information and updates to your care team to help prevent miscommunications, reduce unnecessary hospital visits, and make sure your care is seamless and effective. The process is continuous, ensuring that care remains effective and appropriate over time.

Is care management covered by insurance?

Coverage varies. Some care management services may be covered by Medicare, Medicaid, or private insurance, especially for those with chronic conditions. Care management may also be covered by a long-term care insurance policy to help offset the out-of-pocket expense for private care services. We would be happy to help you explore your coverage options and find the best solution for your needs.

How do I get started with care management services?

Getting started is easy! Simply contact us to schedule a FREE, no-obligation consultation. At the conclusion of the consultation, you will be offered an opportunity to schedule an in-person initial assessment where our care manager will meet with you and your family to discuss your needs, answer questions, and develop a plan tailored to your situation.

Still have questions?

We’re here for you! Reach out anytime - our team is ready to help you take the next step toward peace of mind and quality of life.