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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:

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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.

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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.

Companion Services

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