Coordination of Care Initial Assessment
Our Care Coordinator visits each client at their place of residence to evaluate condition, discuss options, and develop a Plan of Care.
We help identify any programs, community resources, or benefits that might be available for our clients such as: Medicare/Medicaid Services, Private Health Insurance, Long Term Care Insurance, VA pensions, and others. We will work with your long term care insurance provider to accept Assignment of Benefits and will work to invoice providers directly, if permitted by the carrier. We take the worry and the paperwork hassle away and try to make it as easy as possible for you to access any long term care benefits.
Development and Ongoing Plan of Care
We incorporate all the orders and recommendations from your physicians, case managers, healthcare providers, and our own initial assessment in order to develop an effective Plan of Care. This plan will describe all the services required, the proposed frequency, cost of each service, potential equipment and supplies needed, and the possible payment sources.
- This process could start before the client is discharged from the hospital, rehab, or other healthcare facility.
- We will work with the attending physician, discharge planner, family, and the client to determine the proper Plan of Care and agree on the specific goals to maximize the healing process.
Plan of Care – From Initial Assessment to Ongoing Care Management:
Every client receives an individualized Plan of Care. It’s our way to ensure you receive the service you need and everyone is prepared for the care that needs to be delivered.
- Step 1: The Initial Call & Meeting: From the moment you call our office, we begin considering the specific needs of their loved one. On the initial call, we ask questions to form a needs assessment. Then we set up an in-home visit with the family – including the family member who may ultimately benefit from our services. This visit allows us to gather even more information, answer questions and let you know how your loved one can benefit from Assisting Hands providing care.
- Step 2: Certified Nurse Assessment: Our Certified Nurse and Care Coordinator visits each client and/or family member at their place of residence to evaluate condition, discuss options, and develop a Plan of Care.
- Step 3: Plan of Care: We incorporate all the orders and recommendations from your physicians, case managers, healthcare providers and our own initial assessment in order to develop an effective Plan of Care. This plan will describe all the services required, the proposed frequency, cost of each service, potential equipment and supplies needed and the possible payment sources.
- Step 4: Caregiver Matching and Assignment: Every time a new caregiver is assigned to a client, he or she receives a copy of the plan of care and discusses it with a nurse or care manager. By looking at the whole situation, we’re better able to provide your client with the best caregiver possible. Of course, if there are ever any concerns about a specific caregiver, we can search for and provide a replacement in very little time.
- Step 5: Ongoing Management and Check-Ins: Plans of care are continuously updated, as a consequence of supervisory visits, experience accumulated on the case by our caregivers, and interactions with the client, healthcare professionals or family members. Every update is shared with all caregivers assigned to a client, and case managers follow up with individual aides to ensure adherence to the updates.
Assisting Hands is able to provide Non-Medical Home Care services in the comfort and safety of your own home. We will also assist in coordinating and referring other services needed such as:
- Durable Medical Equipment
- Home Modifications
- Medical Alert System
- Community Based Programs
- Transportation Services
- Coordinating Doctor’s Appointments
For more information, call us in MD at 301-363-2580 or in VA at 703-556-8983.