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What is a care coordination assessment and how does this work?

At ElderCARE, we always begin by listening to you and developing a clear understanding of what matters most. Our assessment is completed based on your needs and preferences with an understanding that this can be an overwhelming process. We will seek to understand your current living situation, emergency contacts, doctors, health history, medications, home safety and identify any needs or indicated services.

Once we have completed the assessment, we partner with you to create a customized care plan which becomes a road map for navigating your current and future needs. The care plan could range from supporting health care by coordinating medical providers and attending doctor’s appointments, to home safety needs and support services. We can also make recommendations to other professional services like attorneys, home modification experts or technology resources.

In addition, we can also support transitions from the hospital or skilled nursing facility by providing education and recommendations around the next level of care and attending care plan meetings at facilities to advocate for your needs. We can also provide regular visits and monitoring to meet any ongoing needs.

We will also introduce you to CareTree, a mobile application medical record that we use to simplify communication with you, your family and providers. This tool will be a centralized resource for communication and updates with family or other professionals. However, if more traditional communication strategies are preferred, we can also accommodate those requests.