Care Management Services for Home Care Clients

Create a full spectrum care plan to help you live your best life

Fedelta Care Management's RN and MSW Care Managers provide families with a variety of services designed to meet the care needs of those who are aging, recovering, chronically ill, disabled, or have special needs. Call us now to receive a complimentary care management consultation with our care managers to decide if care management is the right fit for you or your families needs.

• Long-term planning review and care management consultation
• Crisis and Emergency Prevention
• Care Management for Emergencies
• Training for Families or Caregivers
• Living Well with Chronic Disease
• Wellness Checks
• Family Care Conferences

 

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Long-term Planning Review and Consultation

Estimated Investment Time is 1.5 - 3 Hours

Identifying gaps in a long-term aging plan can avoid unnecessary surprises. Knowing and preparing for the realistic cost of care needs and legal protection will ensure a successful aging experience.

• Review of chronic conditions, family medical health history, legal aspects, financials, and end-of-life wishes.
• Identify location of crucial documents such as DPOA, Living Will, and POLST.
• Care Manager will connect client to resources to get documents in order if needed.
• Identify goals for care and provide basic quote for common costs associated with aging.

 

Crisis/Emergency Prevention

Estimated Investment Time is 2 - 4 Hours

Navigating the complex medical system can be cumbersome, especially after experiencing an emergency or crisis. Families often experience unnecessary hospitalizations, missed administration of crucial medications, inappropriate medication adjustments, being sent to the wrong hospital system, or a lack of communication with providers.

• Development of a crisis document that is posted on the door in a plastic cover that includes list of medications, allergies, diagnosis, current and past medical history, special instructions, preferred hospital, medical insurance card, emergency contacts, POLST form, and DPOA document.
• Connect clients with resources to complete any missing documents.

 

Care Management for Emergencies Only

Estimated Investment Time is 30 Minutes for Setup

Now families can go on vacation or deal with their own emergencies, knowing that their loved ones dedicated care manager will be there to coordinate communication during emergencies until a family member is able to be present. After hours rates apply.

• The client or family will release the clients medical information, list of medications, allergies, diagnosis, current medical issues, medical history, special instructions, preferred hospital, medical insurance card, emergency contacts, POLST form, and DPOA document to their dedicated Care Manager.
• Your dedicated Care Manager will upload this information into Fedelta Care Managements system in case of emergencies.

 

Individualized Training for Families or Caregivers

Estimated Investment Time is 2 - 4 Hours

Clients who experience unique and complex behaviors can avoid disruptions at home when the family or caregivers are prepared and trained. This can be especially challenging with advanced dementia, mental illness, cognitive impairment, developmental disabilities, or special needs. A better trained caregiving team translates to consistent, stable care and a higher quality of life.

• Your dedicated MSW Care Manager will assess behaviors before assembling an individualized training guide. The guide will include tips, advice, educational videos, recommendations, or information for local training events.
• Your individualized guide includes information that can be re-used for all new caregivers.
• If needed, you will receive recommendations or referrals to specialists to assist in the management of behaviors.

 

Living Well with Chronic Diseases

Estimated Investment Time is 2 – 4 Hours

When steps are taken to ensure that chronic diseases are well-managed, quality of daily life can be greatly improved. Lifestyle changes can lead to a reduction in medication, less doctors appointments, and fewer hospital admissions.

• Your dedicated RN Care Manager will assess your chronic disease before providing nutritional advice, recommendations to physicians or specialists, an exercise plan, a personalized safety assessment, or home equipment recommendations.
• We recommend hiring your RN Care Manager to provide monthly wellness checks to ensure the successful implementation of lifestyle changes.

 

Wellness Check

Estimated Investment Time is 1.5 Hours Weekly, Monthly, or As Needed

Your dedicated Care Manager will provide wellness checks to help prevent crisis by identifying potential risks. Wellness checks entail routine or unannounced home or community visits.

• Your dedicated Care Manager will assess the quality of care and identify any gaps in safety, as well as any changes in physical, social, or mental status.
• The Care Manager will provide professional recommendations and referrals to specialists if needed.
• If needed, the Care Manager will share wellness check updates with family members.

 

Family Care Conferences

Estimated Investment Time is 2 – 4 Hours

Your dedicated Care Manager will facilitate a discussion regarding your loved one’s care needs. This conference will include distributing care responsibilities amongst families and caregivers, future care needs, and more. Care Managers provide a neutral voice, which can be vital if there are conflicts amongst family members.

• Your Care Manager will coordinate family conferences, either in-person or over the phone.
• Care managers will speak with each family member individually before the meeting.
• If requested, your care manager will create a formal family agreement regarding care and follow up.