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Care Management

Our Care Management program provides services using experienced and specially trained professionals, often social workers or nurses. Individuals who benefit from care management are often in crisis or live alone with no family or support system nearby. Our clients may have multiple medical issues or are easily influenced or confused, often due to age or a physical, mental or developmental disability.

Through regular visitation, counseling, service coordination and advocacy, we assure our clients receive all the services they need to remain living as independently as possible. In addition, when we make referrals for care coordination, we assure dignified and compassionate treatment from partner service providers. (Click here to learn more about our partners.)

Care management services range from a periodic “just checking” visit to intense care coordination, counseling and advocacy. Care managers also guide, educate, and/or supervise caregivers, whether the caregiver is family or hired help. A detailed case note as to the individual’s changing abilities and needs is documented after each phone call or home visit.

Our care managers can provide any or all of the following services:

Assessments and Care Plans

Our initial assessment includes an extended meeting with the individual in his/her residence. During this visit we evaluate the individual’s:

  • Current living environment/safety regulations
  • Psycho-social needs
  • Current support systems
  • Functional levels
  • Cognition

This initial evaluation of the situation is then enhanced with input from family, friends, physicians and any other professionals familiar with the proposed client. Using this information, we prepare a detailed report (verbal or written) clearly describing the current situation and offering options and recommendations to improve the individual’s quality of life. In addition, we can develop a personalized Plan of Care specifically designed for the client with both short and long-range goals.
Once this plan is agreed upon, the Care Manager can help to implement it. S/he can also monitor the client to assure the plan is working through personal observation and communication with the client via telephone calls, in-office and home visits, making adjustments to the service(s) as needed. Here are some of the services a typical plan may include:

  • Advocacy on behalf of the individual to assure quality and appropriate services
  • Assistance with placement into a better residential setting
  • Attendance and advocacy at medical appointments
  • Caregiver education
  • Coordination and monitoring of community services
  • Liaison to long-distance family or friends
  • Referrals to physicians and other health care professionals
  • Supervision and/or coordination of social, medical and financial services
  • Supportive counseling

Home Visits

Among the most critical elements of our care management service is the regular visit to the client’s home, whether it is a private home or a congregate living facility (independent, assisted, skilled and/or group home). We make sure the individual is eating properly, taking medications as prescribed and identify any special help or additional care needed. Home visits may include assistance in reviewing mail, organizing appointments and coordinating other services such as transportation, shopping and medical appointments. For individuals who live at home, we can implement a simple “home chart” used by any care providers to track all services the client receives. We also regularly screen the current living environment for safety and appropriateness.

Care Managers often function as the individual’s medical historian when interacting with medical providers. We also update long-distance family members on the individual’s successes and challenges, offering supportive counseling and guidance. Our Care Managers are excellent advocates and assure all our clients receive appropriate care services as well as dignified and compassionate treatment.

When visiting facility-based clients, the Care Manager reviews the client’s chart and attends inter-disciplinary meetings with facility staff, helping to build relationships that assure superior and attentive care for the client.

Regardless of the client’s type of home, the Care Manager coordinates care among many other professionals and providers to avoid redundancy and errors; s/he maintains summaries of all these services being used. Care plan meetings at MonarchCare determine whether the interventions are working or if further adjustments are needed.

Our Friendly Visitor Project uses trained volunteers to visit clients in a casual and informal way between professional care management visits. Not only does this enhance the individual’s quality of life with one-on-one social contact, it provides a “second pair of eyes” to identify early warning signs and intervention strategies before a major crisis occurs. Care Managers follow-up on these observations with a professional evaluation before their regularly scheduled visit, if warranted.

Care Coordination

Our Care Managers act as coordinator to streamline all services and provide on-going monitoring of those services to assure the highest possible quality of care and life for our clients. Once the Plan of Care is agreed upon, we can coordinate all the selected services, or work as part of a team, using family, friends and other professionals. We make sure all the services are age and culturally appropriate, taking into account the overarching goal of increasing the client’s functional capacity, encouraging the development of appropriate friendships and emphasizing community inclusion. Services that can be arranged by a Care Manager include, but are not limited to:

  • Home health care, companion care and/or housekeeping services
  • Any needed therapies, educational or rehabilitative services (physical, occupational, speech, vocational, art, pet and music)
  • Meals on Wheels or other prepared food service
  • Adult day care, specialty school or a local senior center
  • Arrange for or provide delivery of personal care items
  • Ongoing supply of medications (mail order, delivery, etc.)
  • Regular transportation (Bus pass, ADA Para-transit, etc.)
  • Address healthcare needs – scheduling of medical appointments (psychiatrist, dentist, ophthalmologist, dermatologist, gynecologist, etc.)
  • Determine if advance directives are in place and make professional referrals to assist you to obtain the recommended forms if there are none. (These documents generally help you to avoid the need for a guardianship in the future.)

(Click here to learn more about advance directives)

Relocation and Placement Services

When current living conditions are no longer appropriate, Care Managers assist clients to move into a more suitable environment. This may involve facility recommendations, touring the chosen locations with the client, even coordinating the actual move. We can arrange for supervision of the packing or liquidation of personal belongings and hire a companion to help with the transition. Follow-up to assure the individual is properly settled in the new environment, offering supportive counseling through the transition, ensuring proper transfer of medical records and arranging any needed changes in medical providers are key aspects to making sure the move is a successful one!

Crisis Intervention

Our staff is available 24 hours a day, 7 days a week, and we are prepared to deal with emergencies as they arise. Whether there is a crisis that needs immediate attention, such as a hospitalization or an emergency placement to a safe environment, or a less emergent but nevertheless dangerous situation, such as self-neglect or financial exploitation, we regularly work with local authorities to resolve the crisis, even when it requires legal intervention. Whether we avert the crisis by being local and immediately available, or invoke a legal proceeding, we can help. For more details about the legal interventions available in Florida, feel free to download any of the following documents:

(Click here to learn more about advance directives)