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Our team will work with you to develop an individual plan of care that operates in conjunction with your doctors to continuously monitor your help. This plan of care works in conjunction with device monitoring, regular check-ins and ongoing updates to keep you as independent as possible and living a full life.
We can provide devices such as blood pressure cuffs, scales, glucometers, etc. and monitor for changes in condition. We will also incorporate personal wellness devices you may already use. This monitoring allows our team to proactively review and manage a patient’s current wellness and proactively contact patients and their families should we see signs of decline or changes which should be addressed. These updates are included in our provider updates and provide a better view of overall health.
We understand that both family and paid caregivers have an important role which can be stressful and overwhelming. Our program provides approved caregivers access to the team for support, questions and access to caregiver education and resources. These include personal support available to caregivers based on their geography and needs.
Our resource library is developed and updated by our team and allows you and your family access to services on a physical as well as cognitive and social level. It includes basics such as services through Office of Aging, transportation providers, meal programs, therapy and counseling services. However, we look beyond these basics to programs that impact a full, dignified life. We strive to connect you with programs like online exercise, arts/crafts and cooking programs are offered, as well as individual mental exercises and brain activities to keep you engaged. Also included are social opportunities for in-person and online groups by areas of interest such as bridge, chess and book clubs.
Beyond 24/7 access, our team has regularly scheduled updates with you and your family to ensure we are providing the best support possible. These updates review your health, social engagement, and make sure that you have answers to questions and explanations for any choices you have. This update is at your convenience and can be done via phone, email or text based on your preference.
Our team helps patients and families identify and connect with services in their area to support a healthy life. This includes traditional services such as transportation, companion care, office of aging, meals, therapy & counseling. We also look at broader needs such as financial, legal/advocacy, and both in-person and online social engagement. Whatever the need, our team will help you and your family identify the options and make the connection if needed.
We work with you to build a complete list of your providers who are currently providing care. Each of these providers will be updated with every change to your condition or diagnosis so they are best prepared to support your changing needs. In addition, we regularly update this list with each patient to ensure there are no gaps in communication.
Our team will work with each patient to build a list of family members and caregivers and provide them updates based on your preferences. You set the approved list and the amount of access and updates you wish. Our team then communicates with each person based on their preferences of phone, email or text updates.
You and your families will be able to access nursing support for changing medical conditions. Our nurses will answer questions and explain choices in easy, approachable language. Additionally, they will review changes in condition and medication and provide recommendations and options for you to moving forward.
You will have access to live support via telephone, video, email or text. This support team is available to answer questions, and provide coordination and navigation support. Our nurse-led teams are also available to respond to urgent alerts and coordinate concerns with your provider. Approved family and caregivers can also access the team with questions and concerns.
Patients receive 3 annual calls or video appointments with an RN to discuss updates and fully review changes in diagnosis and treatment. The nurse also reviews all medications to ensure there are no medication conflicts, or issues which should be reconciled with the appropriate doctor. The nurse can also answer any questions or provide explanations for patients and families.
All patients have 24/7 access to a portal for updates and questions.
You can share your code with Local Emergency Response teams so they have your entire medical and medication history on hand when they respond to a call. This saves critical time and allows emergency treatment based on your condition(s) and a smooth hand-off to the emergency department if necessary.
Each patient receives a HIPAA secure, unique QR Code or eTag which contains your full health history. Patients/Families can update the medical record at any time.