GERIATRIC CARE MANAGEMENT Salem Elder Care · Winston-Salem, North Carolina

Managing the moving parts of an older adult's care is a responsibility most families can't carry alone.

We serve as your single, trusted point of contact — coordinating across every provider, monitoring changes, and keeping your family informed. The result is care that is coherent, consistent, and always centered on what matters most.

WHAT GERIATRIC CARE MANAGEMENT IS

Geriatric Care Management is a professional service in which a trained care manager takes full responsibility for understanding, coordinating, and overseeing every aspect of an older adult's care. It is not a single visit or a one-time assessment. It is an ongoing relationship — with your loved one, with your family, and with every provider involved in their care.

At the center of the service is a detailed written care plan built from a thorough evaluation of your loved one's physical health, cognitive and emotional wellbeing, living environment, social circumstances, and existing support systems. From there, the Geriatric Care Manager becomes the hub — coordinating among physicians, specialists, in-home care professionals, attorneys, and family members. Monitoring for changes. Advocating when needs are not being met. Adjusting the plan as circumstances evolve.

WHAT IT INVOLVES

A Thorough Initial Evaluation A comprehensive assessment across every dimension that matters — physical health, cognitive and emotional status, psychosocial circumstances, living environment, and current support systems. Medical records are reviewed under a signed HIPAA-compliant authorization, all relevant parties are interviewed, and an on-site evaluation of the home or residence is conducted when appropriate.

A Written Care Plan All findings compiled into a detailed written report with clear, prioritized recommendations — the guiding document for all care decisions going forward.

Ongoing Coordination & Oversight The care manager coordinates among all providers, monitors wellbeing through regular visits, and keeps families informed through consistent communication and monthly written reports.

Continuous Advocacy We advocate for your loved one at every level — with physicians, facilities, and insurance providers — ensuring their needs and preferences remain central to every decision.

Care Plan Management As needs evolve, so does the plan. We adjust, reassess, and respond so care always reflects current reality.

THE QUESTIONS WE ANSWER

Can my loved one safely remain at home — or, if transitioning from a hospital or rehabilitation facility, is a return home feasible and under what conditions?

Is the current level of care appropriate, or are there gaps that put the older adult at risk?

What care, services, and equipment are actually needed — and how do we put them in place?

WHY IT MATTERS

Families often come to us after months or years of managing on their own, piecing together a picture from partial information and difficult conversations that never resolved anything. They are exhausted, uncertain, and often surprised to learn that a single trusted professional could have clarified things so much sooner.

Geriatric Care Management gives families a shared understanding of the situation and a concrete plan for moving forward. It gives older adults the experience of being truly seen and heard. And it gives everyone involved the confidence that decisions are being made on the basis of accurate, complete, and professionally gathered information.

It is the foundation. Everything else is built on it.

OUR PACKAGES

We offer two levels of Geriatric Care Management depending on your loved one's needs. Both begin with the same thorough evaluation and written care plan. What differs is the scope and intensity of ongoing support.

TIER 1: INDEPENDENT LIVING SUPPORT For older adults who are largely independent but beginning to need a little help

Independent Living Support is for older adults who live independently but need minimal assistance with daily tasks. The Geriatric Care Manager oversees and coordinates non-medical, in-home supportive services — ensuring the right help is in place so your loved one can continue living life on their own terms.

What This Level of Service May Include

  • Light housekeeping and household tasks
  • Transportation to appointments, errands, and social activities
  • Companionship and regular social engagement
  • Standby assistance with activities of daily living
  • Proactive monitoring of health and wellbeing
  • Regular written reports to family members
  • Coordination with physicians and other providers as needed

Who This Service Is For

  • Older adults living alone with no nearby family backup
  • Those recently discharged from a hospital or rehabilitation stay needing temporary bridging support
  • Older adults with mild cognitive changes who would benefit from professional oversight
  • Adult children at a distance who want a trusted professional watching over their parent
  • Family caregivers who need relief from being the primary driver, companion, and coordinator

Who Benefits

The Older Adult

  • Maintains independence and continues living in their own home
  • Receives personalized support without over-medicalization
  • Reduces isolation through regular companionship and reliable practical help

Family Members & Caregivers

  • Relief from day-to-day logistical responsibilities
  • Regular written reports without needing to be present
  • A professional already in place if care needs increase

Primary Care Physicians

  • A reliable partner for patients needing support beyond the clinical setting
  • Reduced hospitalization risk through proactive monitoring

Hospital Discharge Planners & Social Workers

  • A safe, vetted landing point for patients transitioning home
  • Confidence that a professional is overseeing post-discharge wellbeing

Why This Level of Care Matters

The period between full independence and more formal care is one of the most important and most overlooked stages of aging. Older adults at this stage are often managing well enough that no one intervenes — but not so well that there is no risk. They may be isolated, skipping appointments, or quietly struggling in ways a busy family member isn't always able to notice.

Independent Living Support fills that gap — providing professional oversight, reliable practical assistance, and the consistent presence that keeps small problems from becoming serious ones.

TIER 2: COMPREHENSIVE CARE MANAGEMENT For older adults with significant care needs requiring professional oversight and coordination

Comprehensive Care Management is for older adults whose needs have grown beyond occasional support. The scope is broader, the coordination more intensive, and the level of professional involvement significantly higher. This tier is available for older adults living at home and for those in assisted living, memory care, nursing homes, and other care settings.

AT HOME

Beyond the foundation established in the initial evaluation, at-home Comprehensive Care Management includes:

  • Oversight of in-home care professionals, including hiring and ongoing monitoring
  • Coordination among physicians, specialists, therapists, and all other providers
  • Navigation of healthcare and social service systems on the client's behalf
  • Regular in-person visits with active care plan management and adjustment

Who This Service Is For

  • Older adults with complex medical, cognitive, or functional needs
  • Families managing multiple care providers who need professional coordination
  • Adult children at a distance needing a trusted local professional
  • Older adults whose needs have grown beyond what Tier 1 can address

Who Benefits

The Older Adult

  • Remains at home with coordinated, tailored care
  • Has an advocate monitoring their wellbeing at all times
  • No longer navigates the healthcare system alone

Family Members & Caregivers

  • Relief from coordinating multiple care providers
  • A single point of contact for all questions and concerns
  • Monthly written reports — especially valuable for families at a distance

Physicians & Healthcare Providers

  • A knowledgeable partner accurately reporting on day-to-day condition
  • Confirmation care recommendations are being followed
  • Earlier communication when something changes

Elder Law Attorneys & Financial Advisors

  • A reliable picture of the client's actual care situation
  • Confidence that care decisions align with established plans and wishes

In-Home Care Professionals

  • Clear direction, professional oversight, and a care manager to consult
  • Fewer gaps and a higher standard of care for the client

for those living in ALF’s or SNF— THE RESIDENT ADVOCATE PROGRAM

Even in a care setting, residents can fall through the cracks. Needs go unmet. Concerns go unheard. The Resident Advocate Program places a dedicated Geriatric Care Manager in your loved one's corner — ensuring they are seen, heard, and never overlooked.

Beyond the initial evaluation, this service includes:

  • Regular in-person visits to monitor wellbeing and quality of care
  • Direct advocacy when needs are not being met
  • Coordination with facility staff, physicians, and all involved professionals
  • Monthly written reports and consistent family communication

Who This Service Is For

  • Residents who feel lost, unheard, or overlooked
  • Older adults without nearby family to advocate for them
  • Families at a distance who cannot visit regularly
  • Newly admitted residents adjusting to facility life

Who Benefits

The Older Adult

  • Has a dedicated advocate ensuring their needs and preferences are honored
  • Receives more attentive care through regular professional oversight
  • Feels supported, seen, and less alone

Family Members

  • Full transparency through regular visits, reports, and communication
  • A single point of contact who knows the facility, staff, and situation
  • Reduced anxiety for families who cannot be present as often as they would like

The Facility & Its Staff

  • An additional resource on complex cases
  • Care gaps identified before they become problems
  • Better-informed, less adversarial family relationships

Physicians & Healthcare Providers

  • Reliable information on how a patient is doing between appointments
  • Prompt communication when condition changes occur
  • Reduced risk of avoidable hospitalization through earlier intervention

NOT SURE WHICH TIER IS RIGHT?

Tier 1 is for older adults who are largely independent but beginning to need occasional help. Tier 2 is for those with more significant or complex needs requiring ongoing professional oversight and coordination. We are happy to talk through your situation and help you find the right fit.

 

**FREQUENTLY ASKED QUESTIONS**

**How do we know whether Tier 1 or Tier 2 is the right level of care for our loved one?**
The honest answer is that it depends on the complexity of the situation, and we are happy to help you think it through. Generally speaking, Tier 1 is a good fit for older adults who are managing well overall but need some practical support and professional oversight to to maintain that level of independence as long as possible. Tier 2 is more appropriate when there are significant medical, cognitive, or functional needs involved, when multiple care providers need to be coordinated, or when the family needs a higher level of professional involvement to feel confident that everything is being managed well. If you are unsure, start with a conversation. We will tell you honestly what we think is the right fit.

**What does a Geriatric Care Manager actually do on a regular visit?**
Regular visits are much more than a check-in. The care manager is observing the older adult's physical condition, mood, cognitive status, and living environment, assessing the quality of care being provided, and looking for early signs that something may be changing. They are also building the kind of ongoing relationship with the client that makes it possible to notice subtle shifts that a less familiar observer would miss. Findings are documented and communicated to the family and, when relevant, to the physician or other members of the care team.

**We already have home health aides in place. Do we still need a care manager?**
Home health aides provide essential hands-on support, but they are not trained to coordinate care across providers, communicate clinical observations to a physician, identify emerging health concerns, or advocate for the client within the healthcare system. A Geriatric Care Manager does not replace the aides. They monitor them, support them, and fill the professional coordination role that no one else in the care team is positioned to fill. Families with aides already in place often find that adding care management significantly improves the quality and consistency of the care those aides provide.

**Our loved one lives in a facility. Why would they need additional care management when the facility is already responsible for their care?**
Facilities provide care for many residents simultaneously, and even well-run facilities have limits on the individual attention any one resident receives. Residents with complex needs, communication difficulties, or no nearby family are particularly vulnerable to having concerns go unnoticed or unaddressed. A Geriatric Care Manager visits regularly, builds a relationship with the staff, advocates directly for the resident, and gives families the transparency and peace of mind that facility care alone cannot always provide. It is not a criticism of the facility. It is an additional layer of support that benefits everyone, including the facility itself.

**How are families kept informed, and how often can we expect communication?**
Families receive monthly written reports covering the older adult's current status, recent visits, any changes observed, actions taken, and upcoming needs or concerns. In addition to monthly reports, the care manager is in regular contact with the family and reaches out promptly whenever something warrants immediate attention. Many families find that having a single, reliable point of contact who knows the full picture is one of the most valuable aspects of the service.

**What happens if our loved one's needs increase significantly while they are receiving Tier 1 support?**
Care needs change, sometimes gradually and sometimes suddenly. One of the advantages of having a Geriatric Care Manager involved from the beginning is that they are positioned to recognize when a higher level of support is warranted and to help the family make that transition thoughtfully rather than reactively. Moving from Tier 1 to Tier 2 is a straightforward conversation, and because the care manager already knows the client well, the transition is far smoother than starting from scratch would be.

**Is this service only for older adults who are in decline, or can it benefit someone who is currently doing well?**
It can absolutely benefit someone who is doing well, and in many ways that is the ideal time to begin. Establishing a relationship with a Geriatric Care Manager before a crisis means the care manager already knows the client, the family, the home environment, and the care team when a difficult moment eventually arrives. The families who tend to feel most prepared and least overwhelmed during a health crisis are the ones who had professional support already in place before they needed it urgently.