Social Work Care Coordination
Our licensed social workers serve as the primary coordinators of services and resources.
- Identifying services and programs needed by the client
- Care coordination among providers and agencies
- Communicating with insurance companies and service organizations
- Arranging transportation, equipment, and community resources
- Assisting with long-term care planning
- Coordinating transitions between home, hospital, rehabilitation, assisted living, and skilled nursing facilities
- Assisting families with difficult healthcare decisions
- Helping complete applications and required documentation
- Advocating for the patient when concerns or barriers arise
- Service oversight and quality monitoring
- Resolving issues with healthcare providers, facilities, and vendors
- Serving as a single point of contact for family members
Instead of family members spending hours on the phone navigating healthcare systems, our social workers handle these responsibilities on their behalf.
Nursing Care Management
Our nurses provide clinical oversight, ongoing health monitoring, and communication.
- Comprehensive nursing assessments
- Monitoring changes in condition
- Medication review and management
- Coordination with physicians regarding symptoms and treatment plans
- Monitoring chronic disease progression
- Early identification and response to problems before they become emergencies
- Fall risk assessments and prevention planning
- Education for patients and families
- Coordination of laboratory services and diagnostic testing
- Review of hospital discharge instructions
- Ongoing communication with specialists and healthcare providers
- Clinical recommendations regarding appropriate levels of care
Our nurses help families understand complex medical situations and ensure healthcare providers remain informed and coordinated.
Crisis Prevention & Resolution
Our team works proactively to identify concerns early and intervene before they become emergencies.
- Sudden decline in function
- Medication concerns
- Conflicting recommendations from multiple providers requiring professional guidance and advocacy
- Increased fall risk
- Caregiver burnout
- Behavioral changes associated with dementia
- Hospital discharge complications
- Equipment failures
- Hospitalizations requiring rapid intervention
- Missed services or appointments
- Communication breakdowns between providers
- Urgent health changes requiring intervention
When problems arise, our team takes immediate action to coordinate solutions and minimize disruption for the patient and family.
Family Advocacy
Many families live out of state or have demanding personal and professional responsibilities. We serve as your eyes & ears.
- Regular updates to designated family members
- Participation in physician appointments
- Attendance at care conferences
- Ongoing communication between providers and family members
- Advocacy during hospitalizations and healthcare transitions
- Coordination of family meetings and care planning discussions
- Assistance with difficult healthcare and long-term care decisions
- Communication with hospitals, rehabilitation facilities, and care providers
- Coordination of services for out-of-state family members
- Guidance during medical crises and unexpected health changes
- Insurance & Benefits Guidance
- Protecting Patient Wishes
Family members gain peace of mind knowing a trusted professional is actively monitoring their loved one's care.
End-of-Life Planning & Support
For clients facing serious illness or advanced disease, our team provides compassionate guidance and support.
- Advance care planning discussions
- Coordination of hospice services when appropriate
- Coordination of comfort-focused resources
- Family education regarding disease progression
- Bereavement Support for Families
- Emotional support for patients and loved ones
- Chaplain services
- Coordination with physicians, hospice providers, and other healthcare professionals to ensure care remains aligned with the patient's wishes
- Legacy planning assistance
- Funeral and memorial planning guidance
- Guidance Through Advanced Illness
- Guidance and support during difficult decisions
Families find reassurance knowing an experienced team is overseeing every detail, honoring their loved one's wishes, and providing compassionate support throughout the end-of-life journey.
The Benefit to Families
For clients facing serious illness or advanced disease, our team provides compassionate guidance and support.
- Reduced family stress
- One trusted team coordinating every aspect of care
- Expert healthcare guidance
- Improved provider communication
- Confidence nothing is overlooked
- Faster problem resolution
- Professional patient advocacy
- Peace of mind for families
- Legacy planning assistance
- Clinical, social, and spiritual support
- Assistance navigating healthcare, legal, and practical considerations that often arise during advanced illness
- Guidance and support during difficult decisions