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. Comprehensive Assessment & Evaluation:

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

3. Contract For Services:

After the assessment and report of findings, goals are proposed and the senior and/or family will determine if they would like to move forward with proposed plan. If they decide that they would like to move forward, intake packet and contracting for services are completed. 

4. Goal Planning:

LCSW will work with client and/or family to develop a goal plan that addresses the needs identified in the initial assessment.  The goals will help address needs and alleviate current emotional stressors as well as improve health, safety, and environmental concerns. Improved overall wellbeing is always our primary goal.

5. Care Coordination: 

LCSW 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. Collaborates with all providers to ensure optimal  delivery of services and care.

6. Care Management:

LCSW provides ongoing monitoring and evaluation of client's overall wellbeing. Overseeing plan of care with the objective to monitor health, medical care, service delivery and satisfaction, environmental safety, social, emotional, and cognitive wellbeing. Client advocacy is a large component of Care Management to ensure all providers are working optimally for client. Ongoing frequent collaboration among physicians, service providers, and families. Frequent reassessment of goal plans and revising/adding to goals as new needs arise. 

6. 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 will be made. 

*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 elect 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.  If  in WILL CALL status, a quarterly one hour visit is required.