Coordination of Care

Initial Assessment
Our Care Coordinator visits each client at their place of residence to evaluate condition, discuss options, and develop a Plan of Care.

Benefit Determination
We help identify any programs, community resources, or benefits that might be available for our clients such as: Medicare/Medicaid Services, Private Health Insurance, Long Term Care Insurance, VA pensions and others.

Development and Ongoing Plan of Care
We incorporate all the orders and recommendations from your physicians, case managers, healthcare providers and our own initial assessment in order to develop an effective Plan of Care. This plan will describe all the services required, the proposed frequency, cost of each service, potential equipment and supplies needed and the possible payment sources.

• This process could start before the client is discharged from the hospital, rehab or other healthcare facility.
• We will work the attending physician, discharge planner, family and the client to determine the proper Plan of Care and agree on the specific goals to maximize the healing process.

Care Management
Assisting Hands is able to provide Skilled Nursing and Non-Medical Home Care services in the comfort and safety of your own home. We will also assist in coordinating and referring other services needed such as:

• Durable Medical Equipment
• Medication Management
• Home Modifications
• Medical Alert System
• Community Based Programs
• Transportation Services
• Coordinating Doctor’s Appointments