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We focus on six (6) specific areas:
Individual Functioning
- We evaluate the need for occupational or physical therapy, in-home nurses or aids, and medical equipment, and look for ways to achieve maximum levels of independence.
- We evaluate the mobility, continence, and personal safety of the client.
Caregiver Support
- We assist in identification of care giving needs and screening caregivers.
- We provide support to caregivers, helping them to balance their lives between their care-giving role and their personal life.
- We provide the caregivers with education, counseling, and refer them to other resources (chaplain, state agency, support group, etc.) if needed.
Medical Care
- We review and promote optimal medical care consistent with accepted standards of care.
- We assist in selecting appropriate physicians, obtaining referrals for specialists, obtaining diagnostic testing or an alternative level of care if needed.
- We assist in integration of the treatment plan and aggregation of the client’s medical records.
- We evaluate and monitor medication treatment and compliance.
- We will attend appointments with clients at healthcare providers, as needed.
Psychosocial Factors
- We evaluate the internal and external physical environment or safety and accessibility.
- We provide guidance to caregivers and individuals regarding mood and behavioral concerns, and refer them to counseling, support groups, or other resources as needed.
- We monitor behavior to track progress against original assessment.
Nutritional Soundness
- We review eating habits and nutrition, and set a targeted body weight range.
- We provide education and support to client and caregivers to reach and maintain nutritional and weight goals, and provide dietician referral if needed.
Advance Directives Planning
- We educate clients and caregivers about the purpose of Advance Directives, Living Wills, and Durable Powers of Attorney for healthcare, and provide resources as needed.
- We respect, and incorporate into their care, the client’s personal values and final wishes in to the Care Enhancement Plan.
