Provide advocacy to the client’s current situation. Assist with decision-making, setting up short and long term goals. Partner with client’s families or current support system. Facilitate difficult conversations. 

Coordinate and manage transitions between healthcare settings, such as private homes, emergency departments, hospitals, rehabilitation centers, long-term care facilities, palliative care programs, and hospice. 

Arrange in-home services. Communicate and collaborate with healthcare providers and interdisciplinary teams. Accompany clients to medical appointments, attend care plan meetings, and coordinate transportation.

Offer assistance and referrals for advance care planning, including Powers of Attorney, guardianship/conservatorship, VA benefits, insurance, elder law, and estate planning to address the client’s needs. 

Provide support and resources to families facing the challenges of Alzheimer's, dementia, and other cognitive impairments with their loved ones. Arrange cognitive assessments, coordinate in-home services and conduct home safety evaluations. Assist and ease the transition to a memory care community. Find support groups for caregivers and address caregiver burnout. 

Reduce unnecessary hospitalizations and emergency room visits with proactive, continuous care through ongoing health assessments. Address health changes, fall risks, and family concerns, while navigating next steps to provide peace of mind.