Comprehensive Assessment
This is a multi-step process:

1. Initial telephone inquiry to learn about the client's needs and discuss Coaching Caregivers' potential role as care manager.
2. Mailings to the client or responsible party regarding our care management services: brochure, business card, and a service agreement.
3. Once we receive the signed service agreement and retainer, we begin the comprehensive assessment process, which includes a thorough medical, financial, psychological, and social history. The overall goal of the initial assessment is to determine the client's current and potential future needs and also identify any current gaps in the client's existing care. Family members, particularly those with a past or current caregiving role, are asked to provide as much information as they can. Contributions from long-distance family members can be done over the phone or via email.

Formulating and Implementing a Care Plan
In collaboration with the client and the care circle (family members, friends or other professionals close to the client) a short-term and longer-term plan of care is formulated. A written version of the assessment findings and recommended care plan is made available and reviewed. We then utilize our health-care and social-work experience and professional expertise to enact the care plan. This typically involves:

• Consulting with physicians and other health care providers on the client's behalf
• Making the arrangements for facility admissions, transfers, or discharges
• Dealing with insurance companies for needed eligible services
• Arranging for needed in-home evaluations, modifications, equipment and services
• Arranging for comprehensive medical monitoring of frail clients
• Acting as a surrogate in the absence of family or for long distance family caregivers

Ongoing GCM / CM role
Once the care plan is in place, Coaching Caregivers provides routine client monitoring. We regularly find ourselves performing client advocacy and ongoing problem solving, and we often attend care-plan meetings for clients residing in nursing homes or assisted living facilities.

Reevaluating and looking ahead
Over time, a client's needs may change. In these cases, the care plan must be revised. As care managers, we provide ongoing status-change assessments to our clients or their responsible parties. We aim to always assist with proactive decision-making. This is done through ongoing client assessment, and exploration and education around future care-plan alternatives.