How we do it: Ongoing Case Management
Ordinarily we contract for a minimum
number of hours each week. Once the Plan of Care is approved and the family
contracts for its implementation by Sage Case Management, we will take care
of:
1. Screening, training, scheduling, and supervising Caregivers who meet our standards for competence, trustworthiness, and calm. Client and family interview caregivers from our candidate pool and decide which to hire. We find back-ups in case of caregiver emergency.
2. Overseeing Medications: laying out medication schedules, obtaining timely refills, reporting bad/odd reactions, assuring compliance, and monitoring the use of OTC drugs or dietary supplements. This also entails an inventory of all prescription and OTC medications at home and the establishment of a well-stocked first-aid kit.
3. Maintaining a weekly hour-by-hour Schedule of appointments and engagements, home attendant visits, caregiver hours, and medications.
4. Completing daily and weekly Assessments to track baseline physical and cognitive status. This includes a personal visit each day from Sage, during which we will check such home Devices as Lifeline alert modules.
5. Scheduling and covering all Appointments with physicians, dentists, optometrists, labs, acupuncturists, chiropractors, therapists, support groups. This includes the writing up of questions for each medical appointment; making sure the client gets to offices on time; attending appointments whenever it is likely that test results, new diagnoses, or new treatments are to be considered or implemented; acting as translator for clients with speech or hearing impairments; issuing complete, articulate, e-mailed reports soon after each substantial appointment, to keep the family informed.
6. Retrieving, explaining, and querying medical Test Results.
7. Maintaining a list of contacts, including family, close friends, neighbors, physicians, on-call nurses, counselors, standby transport, accountants, housecleaners, gardeners, handymen, and (where appropriate) landlords.
8. Handling all medical
Emergencies, for which we create
beforehand a protocol, a flow chart of personal/ medical
contacts, an Essential Medical History, an Emergency Information
wallet card (with name, DOB, allergies, meds, disabilities, insurance ID,
address, and emergency numbers), and a Kit of items to bring
to the hospital for the client.
We will be present at all visits to local emergency units and admittances
to local hospitals. We will act as advocates for the client in hospitals,
skilled nursing facilities, board-and-care, or other temporary establishments.
9. Serving as Intermediary for the client's connections with the community: social and governmental agencies, religious institutions, interest and support groups.
10. Providing Research on medical options regarding diagnoses/treatment.