Partners

Personalized Care Coordination

Partners

Partners

Partnering with Professionals

Personalized Care Coordination collaborates with a broad range of medical, legal and other community professionals to support the long-term care needs of their clients. This collaboration is especially important when there are changes in their client's condition and close medical attention is necessary.

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Partners

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  • Personalized Care Coordination supports healthcare professionals in:

    • Managing client’s medical needs by making sure they see all of their physicians on a regular basis, understand their diagnoses and the plan for their care
    • Having a solid system in place to ensure health safety and compliance. Including ensuring clients are taking all medications correctly and that there is no confusion with older medication lists or expired medications within the home
    • Maintaining medical records with copies of all visit notes, diagnostic testing, specialist reports, etc. With these records, the care managers ensure that all of the client’s doctors—primary care and the specialists, are fully aware of the diagnoses and treatment plans of all providers
    • Attending medical appointments as needed to ensure comprehensive communication occurs with each medical visit and that the clients understand what was discussed
    • Following clients through hospitalizations and rehab stays to ensure that the they follow-up with their primary care doctors as soon as discharged in order to reduce the incidence of re-admissions

  • Personalized Care Coordination supports attorneys through:

    • Providing detailed care management assessments, including nursing evaluations and customized care plans to assist in complex cases
    • Assessments of clients in crisis to assist with both short and long-term care planning, with projected future costs of care
    • Ongoing care management for attorney/guardians to assist with decision making and planning

  • Personalized Care Coordination supports accountants and trust officers with:

    • Care management consultations to make sure our clients are receiving the appropriate level of care
    • Updates, formal reports and customized care plans to support our clients’ care needs
    • Ensuring the client’s money is being well spent and that there are no issues with fiscal mismanagement or exploitation
    • Ongoing care management of our clients, including attending and scheduling doctor appointments, advocating with doctors, hospitals, etc., and coordinating in-home care and other community services

Serving all of Rhode Island and Southeastern Connecticut.

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