Match client and/or family with local or national support groups, financial assistance and other resources as needed.
Assess for adherence to vaccinations and other preventative health recommendations.
Pain management techniques and resources.
Provide resources for nutrition management and exercise suitable to client's condition
Care Coordination, Navigation & Patient Advocacy
Guidance regarding diagnosis, health condition, and treatment plan.
Help to organize records and make sure insurance claims are paid correctly.
Assist with questions to ask doctor in order to promote shared decision making.
Coordinate care with client's healthcare team, and advocate for high quality care.
Explore treatment options, including clinical research trials.·
Coordinate health appointments, helping to make sure providers have a good reputation and are in-network with health plan or accept Medicare/Medicaid.
Prepare for and attend appointments, if needed; translate medical terminology into layman's terms you can understand.
Hospital visits and monitoring of care during admission.
Post discharge care coordination (transition of care), including medication reconciliation, follow up appointment scheduling, and discharge teaching, as well as on-going monitoring.
Medical debt negotiation and insurance claims resolution.
Assist with application for Patient Assistance Programs for high-cost medications where available.
Third quarter analysis of medical usage and evaluation for upcoming open enrollment. (We do not sell insurance plans.)
On-going assessment for physical and mental well-being.
If advised, daily wellness check-ins for nutrition, medication adherence, fluid intake, daily weight and vital signs, blood glucose for diabetics, and INR testing for those on warfarin (Coumadin).
Patient/family education and caregiver support.
On-call service in case a client has an urgent need, such as a fall or ER visit, or hospital admission.
Coordination of referrals for in-home assistance (aides), long term care needs, hospice, licensed care (physicians, pharmacists, home health), hospitals, family mediation, and more as needed.
Medical equipment management (including maintenance, reordering of supplies, shipping equipment if client moves, etc.).
End of life/eldercare planning (i.e., Advanced Directives, Durable Power of Attorney, Last Will & Testament, etc.) and planning to finance future needs, referrals to Eldercare or Estate Planning attorneys as appropriate.
Conduct 701b assessments and refer for long term care placement when needed.
Advise about straight Medicare and Supplemental (gap) plans vs. Medicare Advantage Plans; perform 3rd quarter analysis to assist with enrollment in appropriate health plan based on needs. (We do not sell insurance plans.)
Assist with Medicare enrollment and Medicaid application if needed.
Referrals if client does not seem to be able to manage finances adequately to keep needs met.
Coordinate handyman for work that does not require a licensed contractor, such as installing grab bars and ramps, bathtub access devices, painting, or even just changing out light bulbs or putting up holiday decorations.
Coordinate seasonal move for "snowbirds" or for clients needing to transition from home to facility.