Geriatric Care Management Services

For some of our client’s an assessment is the first step to building a support network for the long term. Heal at Home is available to implement the recommendations contained in the care plan. Some client’s and their family members feel that it is more time and cost effective to have these services implemented by a Geriatric Care Manager. In some instances clients or their family members choose to implement some of the recommendations while leaving some for our care team to assist with. When you can’t be with your loved one, we can.

Ongoing services are helpful for seniors who do not have a local support network. Our client’s who utilize ongoing services live at home or in facilities. Sometimes they require a few brief visits a week or month. This time is spent updating medical history, coordinating and attending medical appointments, keeping track of currently prescribed medications, addressing any concerns of the senior, caregivers or facility staff. If a medical crisis occurs we are able to assist you.

Our services are based on individual client needs. Some of the services that we provide regularly are:

  • Communicating with Distant Family Members, POAs or Fiduciaries
  • Attending physician appointments and advocating for client’s health care needs
  • Medication management
  • Obtaining and Monitoring Quality In-home Services
  • Securing and Coordinating Proper Medical Care
  • Referrals to Appropriate Specialists and Community Programs
  • Ongoing Monitoring of health and in home care services
  • Assistance in touring facilities and move coordination
  • Facilitating family discussions
  • Efficiency and flexibility based upon a client and family members
  • Crisis intervention to avoid hospitalizations and unnecessary medical interventions
  • Short-term or ongoing assistance for clients with loved ones living at a distance

Benefits of Geriatric Care Management

Care Management & Patient Advocacy Services are offered in a variety of settings.

Heal at Home provides all of these benefits and much more!

  • Short-term or ongoing assistance for clients with loved ones living at a distance.
  • Personalized and compassionate services focusing on the individual’s wants and needs.
  • Continuity of care management by facilitating family communication, reducing the burden on loved ones.
  • Efficiency and flexibility.
  • Cost containment by avoiding inappropriate medical interventions and/or possible duplication of services.
  • Crisis intervention to avoid hospitalizations or unnecessary medical interventions.

A geriatric nurse manager specializes in being a patient advocate, advisor, and problem solver to both the client and their family. The first step is usually the completion of a comprehensive assessment which will identify problem areas or suggest alternatives and improvements to enhance the individual’s quality of life. The care manager can implement the required services, making all the necessary arrangements in order to secure the proper care for their client.  In addition, a care manager can monitor services to ensure peace of mind for all those concerned.

Because of their expertise with seniors and disabled adults, nurse care managers can assist individuals with all aspects of their lives. A nurse care manager has knowledge of resources available locally and nationally to assist clients with their varied needs. The recommendations of a nurse care manager are designed to improve and maximize each individual’s health and quality of life.

A geriatric care manager can ease the burden of caregiving for children, relatives or guardians.  A customized plan of care can be implemented for elders in their own home, in an assisted living community or in a skilled nursing setting. Geriatric care managers provide advice, counsel, care supervision, education and support to preserve and protect the independence and dignity of every client served.

Comprehensive Senior Care Needs Assessment

Our “Senior Care Needs” assessment begins with a comprehensive in-home assessment that addresses Housing, Nutrition/Meals, Medical History and Current Medications, Mental Health/Memory, Legal, Financial, Spiritual and Social needs.

It serves as a road map for recommended services to improve the quality of life for the seniors. Our client’s and/or their family members may receive a written assessment (if requested) that clearly lists the services and equipment that we recommended. It also provides the client and their family members a clear, easy to follow plan of care to have on hand. Our client’s have found this to be invaluable.

Some of the considerations we document include:

Resource Identification: Geriatricians, Elder Law & Estate Planning attorneys, Fiduciaries, Conservators, Home Care provided by Caregivers, RNs and LVNs, Housekeeping services, Housing options, Geriatric Daycare programs, skilled nursing facilities, specialized hospitals, sub-acute rehabilitation programs, and more.

Planning: Matching needs with available options and developing a plan that best fits the needs of the client and family or guardian.

Expediting Application Forms: Assistance in form completion either by one of our geriatric care managers or by referring to the most appropriate professional.

Patient Advocacy: Attending medical appointments, hospitalizations, and nursing facilities, assistance with Social Security, Medicare, Medicaid, secondary health insurance companies, Veterans Administration, Workers’ Comp, and others.

Crisis Intervention: Coordination of emergency care plan, medical advocacy in hospital or acute care environment.

Follow Up

  • Once the care plan has been implemented, the geriatric care manager can continue to provide support to the family and client through regular visits, email updates and telephone calls.
  • Ongoing monitoring is often important to ensure that the elderly adult is receiving excellent care as well as to provide support and reassurance to the older person and to continually assess whether the care plan is adequately meeting the elderly adult’s needs.
  • The geriatric care manager works closely with medical professionals, family members, in-home service providers, and assisted living or skilled nursing home staff to ensure the best possible care for the elderly adult.


  • The cost/fees for geriatric care management services is straightforward.
  • All care management services are billed at an hourly rate.
  • Billing is done on a monthly basis, unless other arrangements are made.
  • In consultation with the care manager, the family and client choose the type and frequency of services to be provided.
  • The scheduling of geriatric care management services is agreed upon in advance and depends on the level of intervention requested.

For more information, contact us for more information and/or a complimentary 30 minute phone consultation with a Registered Nurse (RN) and Geriatric Care Manager!

Office phone 323-424-7335