Geriatric Care Management

Our Geriatric Care Management program helps you assess, coordinate, and manage the range of services a loved one needs to live at home safely. After we meet with the patient and caregiver, a registered nurse and social worker specializing in the needs of the elderly will recommend a plan in writing so you know that your loved one is safe and secure. Your nurse will act as a “case manager” to coordinate your loved one’s medical care, personal and household assistance, escorting to appointments, administering medications, or providing round-the-clock nursing care at home or in a facility. We can also help you access community resources, such as support groups and adult daycare centers.

The program is fully customizable and begins as soon as you need it. Based on the next steps you decide to take, the case manager can coordinate and oversee the team of home health care professionals who will provide care. Our case manager can put together a team from Partners in Care or work with a team that you have arranged yourself. We will continue to evaluate the Plan of Care, and will adapt it as the client’s needs change.

The case manager will:

• Help prevent the need for hospital visits
• Make sure medication is taken properly
• Review and recommend safety issues in the home
• Recommend appropriate community resources
• Monitor a client’s condition and Plan of Care, and adjust as needed

Depending on a client’s specific needs, the personal care team may include:

• A nurse
• A social worker for geriatric case management
• Home health aide(s)
• Rehabilitation specialists (physical therapist, occupational therapist, and/or speech pathologist)
• A nutritionist