ECN Care Management Services

ECN is usually called in when families are unsure of what to do next, or when a loved one is being discharged from the hospital or a rehabilitation center. 

The assessment begins with an interview of the family and seniors to understand their specific problems or concerns.  Depending on the issue, we may suggest implementing any of the solutions identified under our three main service lines: Care Management and Medical Advocacy, Life Transitions, and Life Management.

Care Management and Medical Advocacy: 

  • Complete an assessment by gathering input and objectives from client, physicians, health care providers and family, and identify strengths and areas of need for each client-specific life situation
  • Manage Medications
  • Manage Chronic Diseases such as Alzheimer/dementia, CHF, COPD, Diabetes, Cancer, arthritis, among others
  • Assist in choosing the best treatment option and appropriate care provider and setting
  • Accompany to doctors' appointments and coordinate care among all providers
  • Advocate before, during and after hospitalizations, doctors' visits, ER visits, etc.
  • Reduce unnecessary hospitalizations and ER visits
  • Provide family/caregiver education and support
  • Develop Custom Care Plan to be implemented by ECN professionals and/or the family caregivers

 

Life Transitions:

  •  Help determine the best living arrangement: home care, assisted living or nursing home
  • Conduct financial and quality of life analysis
  • Educate family on payment options for each living arrangement
  • Evaluate assisted-living facilities and long-term care facilities and/or hospice
  • If necessary, acquire required resources necessary to remain in home
  • Develop Advance Directives and End of Life documentation
  • Facilitate family discussion on above and implement decisions
  • Advocate for client at home or in new setting
  • Assist with downsizing or right-sizing your home

 

 

 

Life Management 

  • Evaluate and insure ability to perform Activities of Daily Living such as dressing, grooming, etc. and Instrumental Activities of Daily living such as shopping, laundry, housekeeping, etc.
  • Coordinate the acquisition of home care services such as homemaker services, companion services, personal care services, transportation, adult day care, in-home meals, etc. through Like Family Home Care or another agency
  • Conduct home safety assessments and recommend accommodations
  • Investigate best and most cost-effective health insurance options and resolve billing issues
  • Manage household and assist with bill paying, if needed
  • Coordinate professional services with accountants, attorneys, and financial planners
  • Arrange social activities and accompany to religious services

 

Evaluation and Reporting for all three service lines

  •  Monitor implementation of the Custom Care Plan making revisions as needs change
  • Act as a family liaison and provide periodic status reports to the family
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