Ongoing Services

A customized plan will be developed with the client and family for ongoing services to meet the client's individualized needs.  Charges will be based on the services that you need us to provide.  The following services are just an example of the many ongoing services available:

  • Follow-up / implementation of the care plan
  • Regular phone or direct contact with client
  • Periodic re-assessment and monitoring
  • Health coaching, problem solving, planning
  • Communication with healthcare providers (attending physician visits as needed)
  • Education of care providers
  • Medical management
  • Assistance with advanced directives
  • Assistance with choosing and arranging alternative living such as assisted living or nursing home

Identifying Resources

Resources will be provided to the client based on the client's personal preferences and the individualized care plan.  These resources may include:

  • In-home services
  • Rehabilitation services
  • Senior centers
  • Physician services
  • Legal and financial services
  • Social services / activities
  • Assisted living or nursing home
  • Counseling / support groups

Care Plan

An individualized, written plan of care will be developed and presented during a care conference involving the client and family.  Facilitating agreement between the client and family is a key element of the care planning process.  Education in medication management, home safety, energy conservation techniques, or other tips to maintain independence will be provided as part of the individualized care plan.


Our assessment begins with an individualized comprehensive assessment of the client in his or her home environment.  The assessment includes:

  • Consultation with the client and family members to determine their goals for the initial assessment
  • In-home assessment of the older adult to identify functional, health, nutritional, social, and cognitive needs or abilities
  • Fall risk assessment
  • Home assessment to determine safety risk factors
  • Assessment of the need for durable medical equipment and assistive devices