Navigating the Complexities of Care
With You Every Step of the Way
About
Our care management services are tailored exclusively for families and legal guardians seeking dedicated, private oversight of a loved ones' care at home, within a nursing home, or rehabilitation setting. This service provides expert guidance through every phase of the care journey- whether that be getting additional help at home or navigating the complexities of nursing home care.
With extensive knowledge of medical terminology and healthcare documentation, we serve as a bridge between families, home care agencies, and or facility staff, ensuring that every aspect of care is clearly understood, appropriately documented, and aligned with the person's best interests. We maintain ongoing communication with the care team, advocating for appropriate interventions.
In facilities, we participate in care plan meetings to ensure the resident’s needs are being met comprehensively. When the time comes for discharge, we facilitate a seamless transition, whether to home or to another level of care.
In Facilities
Admission Process
Direct admission from the community vs. from the hospital. Guidance in choosing the best facility while knowing what to ask. We'll make sure there's no surprise bills.
Discharge Home
Assistance with understanding what a "new baseline" means in terms of going home. We'll coordinate equipment, appointments, and home health services so you don't have to.
End of Life
When discharge isn't possible, or long term care (LTC) is selected from the start- end of life care becomes reality at some point. We'll help you have the hard conversations with your loved one about their wishes. If hospice is chosen, we'll help you make the hard phone calls both with agencies and the facility.
Care Planning
Facilities schedule Care Plan meetings without your attendance ability in mind. We can be there when you can't, knowing the right questions to ask. This service is for short term rehab patients with plans to go home, and long-term care residents.
Mental Health Support
A unique service to Silver Compass is the ability to provide 1:1 counseling support while your loved one is admitted to a nursing home. Elizabeth will support their mental health while you balance everything else.
Legal Brokerage
Silver Compass Supports does not provide legal services- but we know who does! We'll connect you with legal firms who can assist with MassHealth, POAs, and Wills.
Additional expertise includes conducting MOCAs, BIMS, PHQ-9, and GAD-7 assessments. Understanding of state surveys, star ratings, when to contact the Department of Public Health vs the Ombudsman, medical terminology, health care proxy documents, guardianships, MOLST forms, Roger's treatment plans, psychotropic medications, and consent forms.
At Home
Case management services are also available for individuals living at home. These services include the coordination of doctors' appointments, equipment, and in-home services such as home health aides. Counseling services can be utilized with or without case management. If Elizabeth notices a need at home, she will make recommendations to the client and their family, or primary care doctor.
