Heart & Soul Elder Care Management

Continuity of Care with Heart

Care Coordination Services Include:

  

All Services are tailored to meet individual needs.




 
Assessment: 

  · In-home Functional/Safety Assessment - referrals & recommendations
 · Evaluation for cognitive, nutritional, social, medical & financial needs

Care Plan:

· Complete Care Plan Report & Implementation
 · Collaboration with doctors, family, trust officers, insurances
  · Long-term financial planning to preserve assets and pay for care

Care Coordination: 

 · Medication Compliance, Oversight & Support
. Complex Case Management
 · Accompaniment to MD Appointments 
 · Support & Education for Depression, Anxiety & Isolation
 · On-going Comprehensive Case Management for stabilization of care
 · Liaison and support for clients’ families who live at a distance
  · Bill Pay/Advanced Directives/Attorney Referrals
 · 24-hour On-Call Availability/Emergency Response
 · Navigating Medical System/Medical - Medicare Assistance
 · Family Caregiver Support  & Education
  · Support & Education for Dementia & Alzheimer's Disease
 · Crisis Counseling & Regularly Scheduled Visits
 · Support at the hospital and settling in back at home



 Supportive Services:

· RN assistance with complex medical conditions
 · Education and Liaison with Hospice
 · In-Home Caregivers & Nursing Assistants
 · Placement Options—referrals and education
  · Information & Referrals to Community Resources
 · Referrals to health specific support groups

 

 

 

 

   
Services Include:

· Home Safety/
Functional Evaluation

· Care Plan Report

· RN Well Care Visits

· Long-Term Care Plans

· Collaboration with
Physicians, Nurses

· Healthcare Advocacy

· Home Health Care
 Home Care Nursing

· Transportation &
Medication Assistance

      · Day program Activities

· Nutritional & Dietary

· Advance Directives
Legal Assist Referrals

· Entitlements

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