— HOSPITAL CARE ADVOCACY

Get the guidance and advocacy you need when a loved one is hospitalized.

When an older loved one is hospitalized — expected or not — the medical system can feel overwhelming and confusing to navigate. Our geriatric care managers serve as expert guides and advocates at every stage, from pre-admission through the transition home and beyond. Based in Winston-Salem, we serve older adults and families across the Triad.

Winston-Salem, NC · Independent & Unbiased Care Management

elderly woman living at home, washing vegetables in her kitchen
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Skilled guidance & care

The 5 Stages of Hospital Support with a Geriatric Care Manager.

Our care managers assess, coordinate, guide, educate, and advocate for the client, their adult children, and family caregivers from the moment a hospitalization is anticipated through the return home and recovery. Whether a hospitalization is planned or sudden, we are here to provide the support and advocacy you need.

Every engagement begins with a thorough initial consultation and intake, including a comprehensive psychosocial and health assessment of the older adult and a caregiver assessment, from which a personalized care plan is developed.

01

Pre-Admission

Preparing the client and family, coordinating with the medical team, and ensuring the home environment is ready for the return — before hospitalization even begins.

02

Admission.

Managing the intake process and ensuring the care team has the complete picture of the client's health history, medications, and personal wishes.

03

Hospitalization.

Serving as the family's eyes and ears — advocating for quality care and keeping communication clear between the medical staff and the family at home.

04

Discharge Planning.

Arranging home health services, reconciling medications, and educating caregivers on what to expect so that discharge doesn't mean care ends.

05

Transition & Monitoring.

Following the client home, monitoring medications and recovery, supporting caregivers, and connecting to community rehabilitation services in Winston-Salem and the Triad.

Every engagement begins with a thorough initial consultation and intake, including a comprehensive psychosocial and health assessment of the older adult and a caregiver assessment, from which a personalized care plan is developed.

How We Work

We support older adults and their families through every stage of a hospital experience - before, during, and after.

The Older Adult

  • Feels less frightened and more informed at every stage. Someone is always explaining what is happening and why.
  • Has a skilled advocate ensuring their wishes, preferences, and medical history are known and respected by the care team.
  • Experiences a safer, better-supported return home with the right services already in place.
  • Is less likely to be readmitted due to close post-discharge monitoring and medication oversight.

Adult Children & Family Members

  • Relief from the overwhelming burden of navigating an unfamiliar and often intimidating medical system.
  • A knowledgeable professional who can interpret medical information and ask the right questions on the family's behalf.
  • Confidence that a parent or loved one is being watched over — especially critical for adult children who live out of town or cannot take time away from work.
  • A clear plan and realistic expectations for what comes after discharge, reducing the chaos of bringing a parent home unprepared.

Family Caregivers

  • Assessed for their own capacity, stress, and needs - not just the patient's - so they don't burn out.
  • Educated and trained on what the returning patient will need, reducing fear and mistakes at home.
  • Connected to respite care, community resources, and support services they may not have known existed.
  • Supported throughout the transition, not just handed a discharge packet and left on their own.

Physicians & Medical Team

  • Confidence that discharge instructions will actually be followed and understood.
  • A care manager communicating changes in the patient's condition post-discharge, enabling earlier intervention before a crisis develops.
  • Reduced likelihood of readmission, which reflects well on both the physician and the hospital.

Hospital Systems

  • Lower readmission rates, which matter both financially and for quality metrics and ratings.
  • Families who feel supported and informed, reducing complaints and conflict on the unit.
  • A trusted community partner handling the post-discharge continuum that hospitals often struggle to manage on their own.

PREVENTING READMISSION

Hospital readmission is costly, frightening, and - in many cases - entirely preventable.

Too many older adults return to the emergency department within days or weeks of discharge, often because of unmanaged medications, confusing instructions, or a lack of follow-up support at home.

A core goal of every engagement is preventing that return trip. Through close post-discharge monitoring, medication oversight, and proactive caregiver support, our care managers work to keep your loved one safely at home and on the road to genuine recovery.

  • Follow-up home visit within 24–48 hours of discharge.
  • Complete medication reconciliation and review.
  • Caregiver education and hands-on training at home.
  • Coordination with the primary care physician and specialists.
  • Connection to rehabilitation and community services in Winston-Salem.
  • Ongoing monitoring and check-ins during the recovery period.
  • Early identification of warning signs before they become emergencies.

Questions About Hospital Care Advocacy?

Do we need to arrange this service before a hospitalization, or can we call once someone is already in the hospital?

You can call at any point. While engaging us before an admission allows for the most thorough preparation, we are equally equipped to step in once a hospitalization is already underway. Families often reach out in the middle of a crisis, and that is exactly what we are here for. The sooner we are involved, the more we can do, but it is never too late to have an advocate in your corner.

What exactly does a geriatric care manager do while my loved one is in the hospital?
My parent's doctors seem competent. Why would we need an advocate?
What is involved in discharge planning, and why does it matter so much?
How do you help prevent hospital readmission?
Our family lives out of town and cannot be at the hospital regularly. Can this service still help us?
How is a geriatric care manager different from a patient advocate employed by the hospital?

Our Promise

Why work with a Geriatric Care Manager?

We serve as the hub of your loved one's care, providing comprehensive assessment and ongoing coordination of care across all domains — medical, emotional, social, and environmental — with a personalized care plan and a single trusted professional at the center. Serving Winston-Salem and Forsyth County, North Carolina.

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Initial Consultation

We begin with a thorough consultation to understand your situation, your loved one's needs, and the scope of the hospitalization. There's no obligation — just a conversation with a professional who has seen this before and can help you think clearly.

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Comprehensive Assessment

A detailed psychosocial and health assessment of the older adult, alongside a caregiver assessment, forms the foundation of everything we do. We look at the whole picture — medical, emotional, logistical, and social.

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Personalized Care Plan

From the assessment, we develop a care plan tailored to your family's specific situation, preferences, and goals — covering every phase of the hospital experience and beyond.

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Active Advocacy & Coordination

Your care manager is present and active throughout the hospitalization — in communication with the medical team, keeping the family informed, and making sure nothing falls through the cracks.

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Transition Home & Ongoing Monitoring

We follow your loved one home. Services don't end at the hospital door. We coordinate the return, monitor recovery, support the caregiver, and connect your family to the right resources in the Winston-Salem community.

Begin the Conversation

No one should navigate a hospitalization alone.

Whether you're facing a planned surgery or managing an unexpected emergency, we're here to help. Reach out today to speak with a geriatric care manager about your family's situation. Serving Winston-Salem, NC and the surrounding Triad region.