Medical care coordination services assist you when you transition from one level of health care to another. These times are often confusing to the patient and their family. As your Medical Care Coordinator I will help you navigate the maze of healthcare services. Those services include assessing the home setting, and obtaining medical equipment. I will also teach family members and care givers the best way to deliver their services. I will meet with providers to ask the questions the patient or family isn’t aware need to be asked.Care oversight as well as medication management is also a service I provide as your Medical Care Coordinator. When a transition in level of care occurs in chronic illness, or across the lifespan as in pediatric developmental needs, or geriatric care needs. Developing a medical cost projection can also be performed.
An example of what I, as your Medical Care Coordinator can do for you:
- Assist you in transitioning from the hospital or home to an appropriate facility
- Assess the home environment for safety and ability to function
- Provide medical specialists as may be needed
- Assistance with transitioning into new living arrangements
- Coordinating relocation
- Coordinate communication among all medical providers
- Coordinate physician’s plan of care and referrals as indicated
- Perform medication management and education
- Conduct Caregiver oversight and education
An example of scenarios I encounter is:
- Your Mom tripped and fell at home and broke her hip. She had surgery and is ready for discharge from the hospital. What’s next? Your faced with choosing a rehabilitation facility, or having her at home with caregivers. She’s unable to bear weight, and needs to use a walker. I will assess her home living situation and her functional capabilities. I will evaluate her support system along with her mental acuity. I will also evaluate the potential rehabilitation facilities and treatment options. I will then present all the options, and together we will make the best decision for the best outcome. I will work with the discharge planner to set up follow-up appointments, order necessary equipment, and set up home health if required.
- Your parent(s) currently live in their own home, yet are having increasing difficulty caring for themselves adequately, in the area of personal care, cleanliness, or nutritionally. One of them may suffer from a form of dementia, or had a recent stroke, of has declining COPD. As your Medical Care Coordinator, I will perform a home assessment and with input from all involved, develop care plan promote health, safety and functionality.
- You have just been diagnosed with a chronic illness, such as Multiple Sclerosis, Lupus, Diabetes, COPD, or Dementia that will require life style changes, home adaptations, and multiple specialists. As your Medical Care Coordinator, I will meet with you and your support system, to determine current level of understanding. I will provide additional information and education. I can also recommend specialists as needed, and set criteria to be aware of when a change in condition is pending. Together we can lay the groundwork for care and needs across the life continuum.
- Your remaining parent lives across the country and is currently healthy but getting older and showing signs of slowing down. Your family has agreed that you will become his/her healthcare and financial power of attorney and she/he will move to your area. Where should he/she go? Independent living, Assisted living, your home. All possible options. We will have an in home assessment performed to determine her current functionality. Combining her/his functionality, age, estimated life expectancy, along with finances, the appropriate living arrangement with associated costs will be explored.
Across the street or across the country YOU are not alone.
