Our Process

1. Free Phone Consultation: 

Call us to hear more information, give a brief synapsis of your situation, discuss pricing and determine how we can best assist your needs. 

2. Contract for Services:

After your phone consultation, if both parties feel services will be a good fit and/or family has determined they would like to move forward with services, an appointment will be set to meet client(s) in their environment to further discuss care needs and initiate contracting. Upon completion of contract and cost for initial contracting/intake evaluation are paid, client will be scheduled for Comprehensive Assessment.

3. Comprehensive Assessment & Evaluation:

A Licensed Clinical Social Worker (LCSW) or Care Manager- team leader will come to your home to provide a comprehensive evaluation of: physical, mental, emotional, social, environmental, financial, functional, safety, and community support service needs. The assessment will identify key problems, strengths, needs and resources. Recommendations will be made and LCSW or CM will propose goals based on assessment needs and desired outcomes. 

4. Goal Planning:

In our care management program, a licensed clinical social worker (LCSW) and Care Manager collaborate with clients and their families to create a personalized goal plan based on the initial assessment.

These goals are designed to address specific needs, reduce emotional stress, and enhance overall health, safety, and environmental conditions. Every plan is centered on improving overall wellbeing, ensuring that clients and their families feel supported, empowered, and equipped to navigate life’s changes with confidence.

Our purpose is to address current challenges, planning for the future needs, reduce emotional stress, and enhance overall health, safety, and environmental conditions with achievable solutions. Our primary focus is always on improving overall wellbeing, helping clients and families feel supported, empowered, and confident in their care journey.

5. Care Coordination:

Our team of licensed and certified professionals provides linkages and arranges community supports and services, provides guidance and support to individuals & families, provides education, collaborates with physicians, hospitals, rehabs, assisted livings, advocates for client and maximizes continuity of care. Collaboration with all providers to ensure optimal delivery of services and care.

Our Care Coordination services involve collaboration between a licensed clinical social worker (LCSW) and a Care Manager to work closely with clients and their families. Together, we develop a personalized goal plan based on the needs identified during the initial assessment.

6. Care Management:

Our Care Managers provide ongoing monitoring and evaluation of each client’s overall wellbeing. We oversee the plan of care with a focus on maintaining optimal health, coordinating medical care, ensuring quality service delivery, and promoting safety in all aspects of life—physical, emotional, cognitive, and social.

A key part of care management is client advocacy. We work to ensure that all healthcare providers and service partners are collaborating effectively and acting in the client’s best interest. Frequent communication with physicians, service providers, and family members helps maintain a cohesive support system.

Care plans are continuously reassessed to reflect changes in health status, personal goals, or daily needs. As new challenges or priorities arise, goals are updated to ensure that every client receives the most appropriate and compassionate support possible.

7. Discharge:

Discharge from The Health Coach, LLC may take place upon achieving goals set forth in goal plan.  If and when a family or client feels that all needs have been met and there is no longer a need for ongoing care management and coordination a discharge plan will be provided. 

*At times families may feel a situation has stabilized and they no longer require frequent care management, but they do not want to discharge completely. They may request to go on WILL CALL status which means they are on hold until they need services again. During WILL CALL status a quarterly reassessment is required.