Comprehensive home safety and health care assessment. Fully written or verbal report with nursing recommendations provided reflecting appropriate level of care required, working in partnership with client and family to close the gaps in care.

Coordination of in-home services medical and non-medical.

Medication management: Registered Nurse will set up weekly or monthly medications and coordinate refills/prescription renewals; act as liaison between pharmacy, client and physician.

Advocacy: Registered Nurse will accompany clients to physician, legal, and other appointments when client requires assistance with communication, physical assistance, etc. Registered Nurse is able to attend facility service plan or care plan meetings representing family members or with the family member and patient to provide support, advocacy, guidance and further education as care is planned for the patient.

Long term care planning to assess potential financial needs to support future care expenses for home or facility location.

Medical/non-medical monitoring in lieu of family members who may live out of town or may leave town for an extended period of time (i. e. vacations, vocational events).

Assistance with coordination of Advance Directives.

Crisis Prevention Strategies, providing anticipatory guidance and support.

Education and Identification of community resources to which one is entitled.

Assistance with Senior Housing Placement; will coordinate tours and accompany on tours of senior living communities upon request.

Assistance with coordination of transition to different level of care, such as moving from a family home to assisted living community or returning home after a lengthy hospital stay.