It can be overwhelming for families or concerned individuals to navigate through the complex health care system and the maze of options available for in-home assistance, housing and other community resources. A care manager assesses the needs and provides direction and assistance and serves as an advocate and liaison between the client and family and service providers.

Care management services can be brief or on-going depending on the needs of the individual. Following is a partial list of services offered by TCS.

• A comprehensive & objective assessment including physical health, mental health, and functional abilities; in addition to social needs & spiritual needs; and housing & safety issues.
• Screening for memory impairment, depression & other mental health issues.
• Comprehensive plan of care to address the individual’s current needs as well as long term needs.
• Supportive therapy for grief, loss & transition issues.
• Coordination of care with physicians, psychiatrists, psychologists, home health agencies, rehabilitation facilities, retirement communities and other community resources.
• Advocacy with physicians, hospitals, facilities, insurance companies, the State, & care providers.
• Assistance with Medicaid qualification.
• Education of clients and family about aging issues, disease processes, community resources, etc.
• Medication monitoring & education.
• Placement assistance in finding the right assisted living facility, skilled nursing facility, adult family home or boarding home.
• Assist with the transition from living at home to a retirement community.
• Crisis prevention & intervention.
• Objective assistance with family conflict.
• Hiring, coordinating & managing in-home care givers.
• Regularly scheduled care conferences involving the client, family, care providers & agencies with the focus on the holistic needs of the client.
• Referral to reputable legal, financial, & home care services along with many other community resources.
• Assist with developing advance directives for end-of-life care.
• On-going monitoring involves regular visits and contact with the client and the service providers to ensure the client’s needs are being met and quality of life preserved.