Individualized Referrals

Individualized Case Management Approach

 
 

"A broad range of services and/or supportive medical, personal and social services necessary for individuals who are unable to meet their basic living needs for extended periods of time."

- California Advocates for Nursing Home Reform (2010)

  • Free 30-minute consultation and resources provided with an evaluation of the Healthcare Financial Profile™ and feedback on eligibility for Medi-Cal or Veteran's benefits.

  • Care Management Reports: Senior Transition Plans that facilitate the immediate plan and long-term plan for care management with a plan of care and resources and recommendations.

  • Coaching and healthcare advocacy for the optimal interdisciplinary plan, as a safety-net for the gaps for continuum of care to enhance the patients’ quality of life and end of life wishes.

  • Pre-planned “fire-drill plans” with a hospital and nursing home pre-selection for rehabilitation or Long-Term Care before it occurs.

  • Successful hospital and nursing home discharge planning for patients, while utilizing recommendations from the Physician’s directives.

  • Comprehensive plan of care that incorporates referrals to long-term care professionals:

            Geriatric Care Managers for ongoing case management

            Geriatric Medical Services (in-home or community clinics)

            Professional In-Home Care Services (private duty vs. home healthcare)

            Home Health (skilled nursing at home)

            Home Maintenance, Transportation and Chore Services

            Home Disability Support and Medical Alert Systems

            Hospice Care Providers

            Elder Law and Estate Planning Advice

            Elder Mediation Services

            Guardianship and Trust Administration / Fiduciaries

            Financial Service Specialists

            Seniors Relocation and Real Estate Specialists

            Pre-Planning, Pre-Need Funeral Providers, and

            Tailored referrals specific to individual need