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• Help with making sense of complexity...

  • Managing complex chronic medical conditions

  • Comprehensive Geriatrics Assessments & Consultations 

  • Medical decision-making capacity evaluations (see below) 

  • Dementia evaluations, education, management, & support 

  • Transitional care- after hospital or nursing home discharge 

  • Pre-facility entry assessments & screenings (see below) 

    • “Is it time?” or “What options make the most sense?” 

    • Providing facilities with recommendations for anticipated plans of care  

    • Assistance with forms necessary for facility entry 

  • Palliative Care, Goals of Care & Advance Care Planning 

    • Understanding options 

    • Completion of important forms- DNR/DNI, POLST, advance care directives  

    • Help with navigating the difficult conversations 

    • Help with home-based palliative care or hospice  

  • Individualized plans of care/recommendations   

  • Education regarding medical conditions, dementia/memory loss, & geriatrics syndromes 

  • Coordinating medical communication 

  • Making sense of medical records, physician visits/communications, test results, plans of care

• What does ongoing medical care management look like?  

  • Help to support & organize the medical care 

  • Flexible & personalized care plans suited to your needs 

  • Services can include: 

    • Availability via phone, e-mail, and/or follow-up house calls  

    • Help with understanding medical conditions, diagnoses, treatment plans, medication regimens & testing results 

    • Help with communicating with primary care providers & specialists to organize care

    • Working to simplify medication regimens 

    • Health advocacy & education for patients in skilled nursing or assisted living facilities  

    • Support with Palliative Care, Goals of Care, & End-of-Life Care​​

      • Navigating conversations​

      • Completing forms like POLSTs, DNR/DNI, advance care directives

      • Coordinating with hospice when/if appropriate

    • Dementia care & support  

    • Investigating options to prevent  or reduce hospital readmissions & ER use 

    • Help with understanding options for care in the home and services to support aging in place 

    • Help communicating with hospital or nursing home teams to understand what's going on and discharge plans 

    • Help with navigating the health system 

    • Work with a care manager to provide comprehensive care & support in the home- the medical, the functional, the social 

    • I am accepting a select panel of patients for primary care.  Please call for more details and to clarify if this could fit your or your loved one's needs.   

• Please see the FAQ section for more details.