Initial Assesment
Every client and family has unique healthcare needs, concerns, and goals. The Initial Assessment is a comprehensive review designed to help identify areas where additional support may be beneficial. During this personalized consultation, I take the time to learn about the client's medical history, current healthcare providers, medications, living situation, support system, and overall needs. This assessment allows me to develop recommendations and determine which services may best support the client moving forward.
What's Included:
• Comprehensive review of medical history and current health concerns
• Medication review and identification of potential challenges
• Discussion of current healthcare providers and services involved in care
• Evaluation of support systems, caregiving needs, and living environment
• Identification of barriers to healthcare management and follow-through
• Discussion of goals, priorities, and concerns for the future
• Recommendations for services and resources that may be beneficial
• Personalized plan for ongoing support, if desired
The Initial Assessment is required prior to ongoing advocacy or care coordination services to ensure recommendations are tailored to each client's individual needs.
Appointment Advocacy
Medical appointments can be overwhelming, especially when dealing with multiple providers, complex diagnoses, medication changes, or important healthcare decisions. Appointment Advocacy provides personalized support before, during, and after appointments to help ensure concerns are addressed, questions are answered, and important information is clearly understood. As a Registered Nurse, I serve as an extra set of eyes and ears, helping clients and families feel informed, confident, and supported throughout the process.
What's Included:
• Initial assessment required before services begin
• Review of concerns and preparation of questions prior to the appointment
• Attendance at medical appointments when requested
• Assistance with communication and clarification during the visit
• Written summary of key information and recommendations discussed
• Follow-up regarding medications, testing, referrals, and future appointments
• Communication with designated family members when authorized
• Assistance coordinating additional healthcare services if needed
Transportation is not included; however, assistance with arranging transportation can be provided.
Medication Support
Managing medications can become increasingly challenging when multiple prescriptions, dosage changes, and healthcare providers are involved. Medication Support is designed to help clients stay organized and informed by providing assistance with medication management routines, refill coordination, and communication with healthcare providers. The goal is to reduce confusion, improve consistency, and provide peace of mind for clients and their families.
What's Included:
• Review and organization of current medication lists
• Weekly pill box setup and medication organization
• Coordination of prescription refills with pharmacies and providers
• Assistance tracking medication schedules and changes
• Communication with healthcare providers regarding medication-related concerns
• Monitoring for potential medication management challenges
• Updates to authorized family members when requested
• Ongoing support to help promote medication adherence
Shasta Senior Solutions does not administer medications, make medication changes, or provide medical treatment. All medication decisions remain the responsibility of the prescribing healthcare provider.
Care Coordination
Navigating the healthcare system can be challenging, especially when multiple providers, services, and appointments are involved. Care Coordination helps ensure that important information is communicated, follow-up tasks are completed, and healthcare services work together more effectively. As a Registered Nurse, I help bridge communication gaps, support continuity of care, and provide clients and families with a trusted resource to help manage complex healthcare needs.
What's Included:
• Coordination between healthcare providers, specialists, and other services
• Assistance scheduling and tracking medical appointments
• Follow-up on referrals, testing, and recommended treatments
• Communication with home health agencies, hospitals, skilled nursing facilities, and community resources
• Assistance understanding care plans and healthcare recommendations
• Support during transitions of care, including hospital discharges and new diagnoses
• Communication with authorized family members regarding care updates
• Identification of resources and services that may benefit the client
Care Coordination services are designed to support communication, organization, and follow-through. Medical decisions and treatment recommendations remain the responsibility of the healthcare provider.
Discharge Support
Returning home after a hospitalization, rehabilitation stay, or skilled nursing placement can be overwhelming. Discharge Support helps clients and families understand discharge instructions, organize follow-up care, and navigate the transition home with confidence. The goal is to reduce confusion, improve follow-through, and help prevent unnecessary complications or hospital readmissions.
What's Included:
• Review and explanation of discharge instructions
• Medication reconciliation and identification of questions for healthcare providers
• Assistance scheduling follow-up appointments and recommended services
• Coordination with healthcare providers, home health agencies, and community resources as needed
• Review of equipment, supplies, and support services recommended at discharge
• Follow-up check-ins to address concerns and ensure continuity of care
• Communication with authorized family members regarding care needs and recommendations
• Assistance identifying potential barriers to a successful recovery at home
Discharge Support is designed to provide guidance, organization, and follow-through during the transition home. Medical treatment and healthcare decisions remain the responsibility of the healthcare provider.
Monthly Support Plan
For many seniors and their families, peace of mind comes from knowing someone is regularly checking in, helping manage healthcare needs, and monitoring for potential concerns. Monthly Support Plans provide ongoing guidance, advocacy, and care coordination tailored to each client's individual situation. Whether support is needed for a few months or on a long-term basis, these plans offer consistent oversight and a trusted healthcare professional to help navigate the challenges that often come with aging and complex medical needs.
What's Included:
• Regular wellness check-ins and ongoing support
• Coordination with healthcare providers and community services
• Assistance scheduling and tracking appointments
• Medication oversight and refill coordination, as needed
• Monitoring for changes in health status or emerging concerns
• Communication with authorized family members regarding updates and care needs
• Advocacy during healthcare encounters and transitions of care
• Access to additional support services based on individual needs
Monthly Support Plans are customized to meet each client's needs and may include varying levels of support based on the frequency of visits, care coordination, and advocacy services requested.
Ongoing Oversight & Wellness Checks
As healthcare needs change, regular monitoring and support can help identify concerns before they become larger problems. Ongoing Oversight & Wellness Checks provide routine contact and observation to help clients remain safe, supported, and connected to the resources they need. These visits offer reassurance for both clients and their families by providing an extra layer of support, advocacy, and communication.
What's Included:
• Scheduled in-home or virtual wellness check-ins
• Monitoring for changes in health status, mobility, or overall well-being
• Review of healthcare needs, concerns, and upcoming appointments
• Medication oversight and identification of potential issues or barriers
• Observation of safety concerns within the home environment
• Communication with healthcare providers when concerns arise
• Updates to authorized family members regarding significant changes or needs
• Recommendations for additional services or resources when appropriate
Wellness Checks are designed to provide support, observation, and advocacy. They do not replace medical care, emergency services, or skilled nursing services.
After Home Health Discharge
Home health services provide valuable support during recovery, but many individuals and families still need guidance once those services come to an end. After Home Health Discharge support helps bridge the gap by providing continued oversight, care coordination, and advocacy to ensure clients remain on track with their healthcare needs. This service offers reassurance during a time when families often feel uncertain about managing appointments, medications, follow-up care, and ongoing health concerns on their own.
What's Included:
• Review of the client's current health status and ongoing needs
• Assistance understanding and following healthcare recommendations
• Coordination of follow-up appointments and services
• Medication oversight and refill coordination as needed
• Communication with healthcare providers regarding concerns or changes in condition
• Monitoring for new challenges that may require additional support or intervention
• Assistance connecting with community resources and support services
• Updates and communication with authorized family members
This service is designed to provide ongoing advocacy, guidance, and support after home health services end. It does not replace medical care, home health services, or emergency care.