Tailored medical and care management services for adults age 65 and older. Comprehensive exams, medication management, care plans, assessments, and holistic support for enhanced well-being.

services include

  • Complete yearly physical exam followed by regular, monthly visits, all within the member’s home
  • Health Data Plan to facilitate efficient and reliable electronic communication and store health data obtained during exams to help members monitor and achieve their health goals
  • Management of complex medical conditions
  • Medication management
  • Identification of needs and social determinants of health through reliable and valid assessment tools

*Embedded geriatric care management, including

  • Care plan creation and management to include referral sources and/or implementation of care plan
  • Comprehensive assessments including financial, environmental, social, functional, psychological, and spiritual
  • *Driving assessments
  • Fall avoidance evaluation
  • Health coaching for client, family, or caregiver
  • Disease education, prognostication, and chronic illness education/support
  • *Alternative living evaluations
  • Pill box support
  • Assistance with procuring a home health aide
  • Home amenity strategies to reduce risk
  • *Mediated discussions with client, family and/or caregiver for goal-setting, education or safety concerns
  • *Alternative therapy solutions for anxiety loneliness and depression such as digital companion support, sound or touch therapy
  • Connect families of dementia clients with resources, education, and product selection for behavioral, sensory or fidget issues

Anticipated Health Outcomes

  • Establishment of goals of care, serious illness discussions and advanced care planning
  • Formulation of a health care proxy or financial power of attorney
  • Medical Orders for Life-Sustaining Treatment (MOLST) form completion
  • Education, management and prevention of delirium or behavioral issues
  • Reduction of high-risk medications
  • Reduction of loneliness
  • Nutritional support
  • Identification and management of geriatric anxiety and/or depression
  • Reduction in hospital admissions and/or urgent care visits
  • Provisional resources/educational strategies for skin breakdown
  • Enhanced family/caregiver awareness of the ageing process and chronic illness management
  • Reduction in pain through palliative care measures and treatment, both holistic and medical
*Starred services may incur an additional hourly fee due to complexity and time utilization. Some of the services are third party referral sources