Our Integrated Practice Model is based on the principles of geriatric medicine, which includes ongoing assessments, evaluations, monitoring and care coordination. Care Managers are central to the model. The Care Manager, who is a registered nurse (RN) or master’s level social worker (MSW), leads and directs a team in the continuum of care. The team is selected for their expertise in geriatric care.

Care Managers are central to the model.

An expert Care Manager is assigned to supervise and coordinate the delivery of all aspects of a clients care, following care management guidelines of the American Geriatrics Society. Responsibilities include:

• Medical and functional assessment, social stimulation, counseling, assistance with transitioning to new environments and maintenance of a safe environment
• Advice, coordination and collaboration with professional and outside providers
• Educating the family about chronic disease and emotional needs
• Developing a Care Plan that provides recommendation for both short-term and long-term care, and allows for change as needed
• Communicating with the family to explain the Care Plan and steps needed to execute it and ensure appropriateness of health and social services
• Keeping the primary and specialist doctors well informed

The Team

Members of the care team, work under the supervision and coordination of the Care Manager. All activities are documented in a web-based, centralized computer system. This provides printable reports for families and doctors to be informed of ongoing care decisions and improved coordination within the care team.

Members of the team include:

Nurses

who perform duties that include treating and educating clients about various medical conditions, and providing advice and support to clients, family members and physicians.

Social Workers

who help people function the best way they can in their environment and mediate and solve personal and family problems. They have knowledge of community resources and coordinate care among healthcare and other professionals.

Exercise and Nutrition Specialists

who assess the client’s diet and engage the client in regular physical and cognitive activity adapted to their level of functioning.

In-Home Caregivers

who assist the client with all Activities of Daily Living including bathing, dressing, eating, moving, and toileting as well as the Instrumental Activities of Daily Living such as shopping, cooking, making sure the client is comfortable and without pain, enhancing their quality of life and comfort.

Healthcare Coordination

to ensure optimal client care. We collaborate with other healthcare providers, including physicians and rehabilitation therapists, to provide their specialized services.

Legal and Financial Coordination

to ensure appropriate planning. We collaborate with lawyers and financial advisors to provide the necessary planning.