Our Services

Issues related to the aging process can be overwhelming for seniors and family members. Geriatric Care management refers to a comprehensive suite of services and activities that help with chronic or

complex conditions that come with aging.

Each client has unique goals in aging and may face unique barriers to these goals as well. Our strategy is to tailor our services, with input from clients, to meet their specific needs. We look to provide a variety of community based, insurance covered, and private pay recommendations whenever possible. We also strive to align services to reduce cost and potentially harmful duplication of these services.

Care Management by Natalie maintains a deep and current knowledge of community resources to support all aspects of the aging process. Our team consists of nurses, social workers, and dietitians who are passionate about advocating for and connecting our clients with the experts that can address their goals.

Better understand your condition, medications,
and treatment options
Identify health risks and steps you can take to improve your health
Connect with support and services in your local community
Find behavioral health services and care for other special needs
Improved clinical outcomes
Reduced use of high-cost acute care services
Expanded communication between clients and healthcare professionals
More primary and/or preventive care visits
Fewer duplicative tests and procedures
Higher patient satisfaction

Benefits of Care Management
Typically Include:

Our Approach

Advocacy: We advocate for what is best for each individual client.

Client participation: When the client is an active member of the care team and participates in setting their own health goals, healthcare outcomes often show improvement. Having a sense of control over and understanding of one’s own health improves the likelihood of keeping up with appointments, medications, and general behavioral health.

Care team participation: It is equally important for the primary care physician and any doctors seen regularly to be active members of the care team. This fosters collaboration between all providers involved in the client’s care.

Communications: Keeping clients and their caregivers continually updated on the client’s progress is a critical aspect to care management. Good communication means clear and consistent communication between all members of the team, especially the client.

Understanding: Your care management team's goal is to have a deep level of understanding with each of their individual clients. This ranges from knowing their habits and preferences to being sensitive to
cultural backgrounds.

Support: Clients, especially those with chronic conditions, rely heavily upon support systems. Care managers become a part of those
support systems.

Comprehensive Care Management

A dedicated care team
A comprehensive care plan around short term and long term goals for aging
Assessment of medical, functional, and psychosocial needs
In home visits
Assessing various risks in the client’s home and environment
Monitoring care gaps and ensuring appointments are scheduled and kept
Advise and provide recommendations on different care structures including in-home support to age in place, day programming, and community settings.
Accompaniment, and facilitation of medical appointments
Ensure timely recommended preventive services
Review medications and any potential interactions
Oversee the client’s medication self-management
Coordinate and communicate with home, agency, and community service providers
Educate the client, family, guardian, or caregiver to support self-management, independent living, and activities of daily living
Assess and support treatment adherence, including medication management
Identify available community and health resources
Help the client and family access needed care and services
Coordinating and sharing client health information promptly. Continuous client relationship with chosen care team member
Health care proxy
Health care power of attorney
Develop a proactive plan around medical emergencies

Coordinate follow up care when transitioning from hospital to rehabilitation setting, without a service gap
Create hospital-to-home program
Supporting a transition to a community setting
Review discharge summary, or continuity of care documents
Review the client’s need for, or follow-up on, diagnostic
tests and treatments
Ensure medical equipment and caregivers are in place
prior to discharge
Interact with health care specialists who address client’s system-specific problems
Advocate with the medical team keeping the client's
goals kept in focus
Educate the client, family, guardian, or caregiver on understanding of medication changes. Awareness of signs for when they should seek medical attention
Address unanswered questions regarding their hospitalization.
Facilitate follow-up with primary care and/or specialty providers.
Establish or reestablish referrals and arrange needed community resources
Ensure every medical provider is updated on changes and current plan of care.

Care Management Services Following A Medical Event

Advance Care Planning

Ensure our clients have had the necessary conversations around treatment, and end of life wishes.
Help facilitate conversations to provide clarity around medical wishes
Organize, review, and ensure appropriate documentation is in place.
Connect with physicians and lawyers to formalize wishes.

Light Housekeeping – including but not limited to vacuuming, dusting, dry mopping, dishwashing, wiping down kitchen and bathroom sinks and counters, and changing beds
Laundry and linen service include washing, ironing and folding clothes
Preparing meals and snacks according to the care plan
Running errands for or with a client including grocery and clothes shopping.
Provide transportation for a client to doctor appointments, friends, family members, or stores.
Observe and report changes in the client’s physical condition, behavior or appearance to their Care Manager.
Provides companionship for the client. This includes accompanying client on walks, trips to social/recreational activities, assistance with hobbies, etc.
Medication reminders
Maintain client confidentiality and maintain a safe environment.