Care Management is a four part process designed to make sure you get the best care possible.
Sometimes called Case Management, it consists of:
- Care planning, and the development of a care plan
- Implementation of the care plan
In the assessment phase, we do an in-depth interview with the client, family, physician, and others who are involved in the care of the client. It includes looking at health, physical strength and deficits, social and recreational needs, support systems, lifestyle, medication and medical profile and housing. The assessment may include calling in another professional such as a physiotherapist, occupational therapist, geriatrician, etc., who can zero in on your needs.
Then we develop a Care Plan. A Care Plan is an action guide to meeting our clients needs so that they maintain as healthy and independent a lifestyle as possible. It is a plan for all the areas of someone’s life where they might need support. It can include plans for relocation to supportive living, assisted living or a nursing home. Or it might mean setting up system to keep you at safely at your own home. It might mean making sure that nutrition is adequate or that bills are being paid and banking is being done. It includes monitoring medication, working towards rehabilitation, and medication reviews. It often entails choosing a home care company and bringing in home support workers who can help with personal care, provide companionship, and help with practical tasks such as laundry, shopping, housekeeping, and meal preparation. It often includes a recreational and lifestyle component that fits with your abilities and needs.
We then can help to implement and monitor the Care Plan. This may entail seeing you weekly, monthly, or even several times a week, monitoring home support workers, liaison with various community organizations, going to the doctor’s office and making sure that the right questions are asked and the right information is given and gotten. We report regularly to family, physician or whoever has employed us.
The care plan is continually evaluated. Over time, we look at changes in the client and the environment to insure that the needs for which the plan was developed are in fact being met. When it is not, we revise in consultation with our client and their family and caregivers.
You can choose any part of the Care Management process. We can simply do an assessment with you, or do an assessment and develop a care plan for you to put into place, or we can do all of that and monitor someone’s care.