Geriatric Care Management in Winston-Salem, NC
Whole-Person Care that Brings Clarity and Peace of Mind
Geriatric Care Management is a personalized service that helps older adults and their families navigate the challenges of aging with confidence. At Salem Elder Care, every care-management relationship begins with a comprehensive assessment of the older adult’s daily functioning, living environment, support system, values, and goals. This foundation makes it possible to develop recommendations and a care plan tailored to the person’s individual situation.
Building on that foundation, I coordinate services, communicate with providers, monitor changing needs, and provide advocacy throughout the care process. Whether assistance is needed for a single challenge or continued involvement over time, the focus is on clarity, continuity, and a thoughtful path forward.
Families often find themselves navigating difficult decisions. You may be asking:
Can my loved one safely remain at home - or, if transitioning from a hospital or rehabilitation facility, is a return home possible?
Is the current level of care appropriate, or are there gaps that put our loved one at risk?
What services and equipment are actually needed — and how do we put them in place?
Who can we trust to provide care for our loved one?
ONE PROCESS, THREE LEVELS OF SUPPORT
One Process, Three Levels of Support
Every client and family is different, and the level of support that is right for you depends on your unique needs, circumstances, and goals. Salem Elder Care offers three levels of geriatric care management designed to provide the appropriate degree of coordination, oversight, and advocacy for your current situation.
LEVEL ONE
Independent Living Support
For older adults who are largely independent but would benefit from a little assistance. This service fills the gap between complete independence and more formal care. Salem Elder Care helps identify, coordinate, and oversee the non-medical services older adults need to remain safe and independent at home.
Building on the initial assessment and personalized care plan,
- Light housekeeping and household tasks
- Transportation to appointments, errands, and social activities
- Companionship and meaningful social engagement
- Support with personal care and daily routines, when needed
- Proactive monitoring of health and well-being
- Regular updates for family members
- Coordination with physicians and other providers, as needed
Independent living support is an excellent fit for:
- Older adults living alone without nearby family support.
- Older adults returning home after a hospital or rehabilitation stay who need short-term support during the transition.
- Older adults experiencing mild cognitive changes who would benefit from professional oversight.
- Adult children who live at a distance and want the peace of mind of having a trusted professional oversee and coordinate their loved one’s care.
- Family caregivers who need support coordinating additional supports, appointments, transportation, and other day-to-day responsibilities.
The benefits of Independent Living Support include:
- Older adults maintain their independence and continue living safely in their own home with personalized support and practical assistance tailored to their needs
- Family members gain peace of mind and relief from day-to-day caregiving responsibilities, knowing their loved one has reliable support and professional oversight.
- Families stay informed through regular communication and updates about their loved one’s well-being, with the reassurance that a trusted professional is already in place if care needs change.
LEVEL TWO
Comprehensive Care Management
For older adults with significant care needs who wish to remain safely at home. This service is designed for older adults whose needs have grown beyond occasional support. As care becomes more complex, Salem Elder Care provides the coordination, monitoring, and advocacy needed to help families navigate changing needs with confidence. Our goal is to support older adults in remaining safely at home for as long as possible.
Building on the comprehensive assessment and personalized care plan, Comprehensive Care Management may include:
- Oversight of in-home caregivers, including assistance with hiring, coordination, and ongoing monitoring.
- Coordination among physicians, specialists, therapists, home health providers, and other members of the care team.
- Medication adherence support, refill coordination, and communication with families and licensed clinicians.
- Navigation of healthcare and community resources on client’s behalf.
- Advocacy during medical appointments and hospitalizations, communicating our client’s needs, preferences, and goals across the continuum of care.
- Regular in-person visits, with ongoing assessment and adjustments to the care plan as needs change.
Comprehensive Care Management is an excellent fit for:
- Older adults with complex medical, cognitive, or functional needs who require ongoing care management and coordination
- Families managing multiple care providers who need professional care coordination.
- Adult children who live at a distance and want the peace of mind of having a trusted local professional oversee and coordinate their loved one’s care.
- Families who want to help a loved one remain safely at home but need professional guidance and ongoing coordination to make that possible.
The benefits of Comprehensive Care Management include:
- Older adults are able to remain safely at home longer with coordinated, personalized care and a trusted professional overseeing the logistics of their support.
- Families gain relief from the responsibility of coordinating multiple providers, with one trusted point of contact to help navigate questions, concerns, and changing needs.
- Long-distance family members receive regular communication and updates, providing reassurance that their loved one’s care is being closely overseen and coordinated.
- As care needs change, families have the reassurance of an experienced care manager who can anticipate challenges, coordinate timely adjustments, and help avoid unnecessary crises whenever possible.
LEVEL THREE
The Resident Advocate Program
For older adults living in an assisted living, memory care, or skilled nursing community. Older adults living in senior communities can benefit from individualized support- The Resident Advocate Program provides our clients with a consistent presence through regular visits and advocacy so their care remains individualized and responsive within a larger community setting.
Beyond the foundation established through the initial assessment and personalized care plan, the Resident Advocate Program may include:
- Regular in-person visits to provide independent oversight, monitor quality of care and quality of life.
- Communication and coordination with community staff, physicians, specialists, therapists, and other members of the care team, keeping everyone informed and working toward shared goals.
- Medical appointment coordination, hospitalization support, and guidance through care transitions to provide continuity and reduce communication gaps as needs change.
- Advocacy during care conferences, medical appointments and hospitalizations to help ensure your loved one’s needs, preferences, and goals remain at the center of every decision..
- Support for social and emotional well-being, encouraging meaningful engagement, social connection, and activities that reflect our client’s interests, preferences, and sense of purpose.
- Advance care planning and documentation review to help ensure your loved one’s wishes are current, clearly documented, and communicated.
- Regular communication and written updates to keep families informed about their loved one’s well-being, changing needs, and recommendations.
The Resident Advocate Program may be especially beneficial for:
- Older adults without nearby family to provide regular oversight and advocacy.
- Adult children and other family members who live at a distance and want a trusted local professional to provide oversight, advocacy, and regular updates.
- Older adults who are adjusting to a recent move into assisted living, memory care, or skilled nursing.
The benefits of the Resident Advocate Program include:
- Families have peace of mind knowing an independent professional is providing ongoing oversight, advocacy, and continuity of care.
- Older adults benefit from having a trusted, consistent advocate who knows them personally, helping them feel supported, heard, and connected.
- Changes in health, function, or well-being are recognized early, allowing concerns to be addressed before they become larger problems.
- Families experience greater confidence and less anxiety knowing there is one trusted professional who understands their loved one’s situation and serves as a consistent point of contact.
- Your loved one’s preferences, goals, dignity, and quality of life remain at the center of every decision through ongoing independent advocacy.
- Families stay informed through regular communication and written updates, while physicians and other healthcare providers receive timely updates that support coordinated, responsive care.
OUR CARE MANAGEMENT PROCESS
01. Comprehensive Assessment.
At the center of the service is a comprehensive assessment that provides an understanding of our client’s health, functioning, support system, living environment, and personal goals.
02. Personalized Care Plan.
Following the assessment, I develop a written, personalized care plan that reflects the older adult’s goals and preferences, identifies immediate priorities, and outlines practical recommendations and next steps.
03. Ongoing coordination, oversight & advocacy.
I coordinate services, monitor changes, advocate when needed, and keep family members informed. As needs change, the care plan and recommendations can be reviewed and adjusted to remain responsive over time.
Is it time to hire a Geriatric Care Manager?
There often comes a point when the challenges of aging become more complex and families find themselves spending increasing time coordinating care, gathering information, and making difficult decisions.
A geriatric care manager brings experience, perspective, and ongoing support—helping older adults and their families understand their options, coordinate care, and make informed decisions as needs change. With a trusted professional keeping sight of the bigger picture, families can spend less time managing logistics while older adults have an advocate focused on their goals, preferences, and well-being.
What changes when you have a Geriatric Care Manager?
Begin the Conversation
Whether you are planning ahead or facing new challenges, I am here to listen, answer questions, and help you identify the next best steps.