Care Management is a four part process. It includes an assessment, the development of a care plan, implementation and monitoring of that care
plan, and ongoing evaluation of the plans effectiveness and benefits..
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 their health, physical strength and deficits, social and recreational needs, support systems, lifestyle, medication and housing. The assessment may include calling in another professional such as a physiotherapist, occupational therapist, geriatrician, etc., who can zero in on the clients needs.
After the assessment, 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 can include plans for monitoring medication, for rehabilitation, medication review, for relocation to supportive living or a nursing home. It might mean making sure that nutrition is adequate or that bills are being paid and banking is being done.
After we have developed a care plan, we then help to implement and monitor it. This may entail seeing the client several times a week, monitoring their home care, liaison with various community organizations, and making sure the client arrives at the doctor's office on the right day at the right time.
We report regularly to family, physician or whoever has employed us.
The care plan is continually evaluated. 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.
