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Geriatric Care Management 

Geriatric Care Management is a specialized program that serves seniors and their families.  A Nurse Care Manager assists the individual and the family develop a comprehensive plan of care personalized to meet all physical, functional, psycho social, environmental and safety needs of the client. 

Our goal is to preserve the client's health, ensure a safe environment congruent with the client's needs, and improve quality of life through ongoing monitoring, assessment and advocacy.

 

Home Care Partners 

Home Care Partners is a specialized program that assists individuals living independently in their own homes. We are dedicated to helping clients lead dignified, independent lifestyles in the comfort of their homes while providing quality care and support.

Services available include: Personal Care, Companion Services, Homemaking Services, Caregiver Respite.  

 

Care Advantage Partnership

Care Advantage Partnership has been developed to partner with assisted living programs and Residential Care Facilities for the Elderly and other health care professionals to implement a comprehensive clinical plan of care for individual clients and their families.  Our Nurse Care Manager partners with   your facility to complement the traditional social model of care by implementing a clinical component that includes all of the benefits of care management and professional nurse consulting specific to the facility's, client's and family's needs.

 

Chronic Disease Management

Following a comprehensive assessment, our focus is developing and implementing an individualized care plan that maintains the maximum level of functioning possible through health promotion and symptom management of chronic diseases such as Diabetes, Chronic Kidney Disease, Chronic Pulmonary Disease, Arthritis, Neuropathy, Vision and Hearing Impairment. 

Also, we specialize in management of neurological diseases such as Multiple Sclerosis, Parkinson's Disease, Alzheimer's, and Dementia.

 

Medication Management

Daily or bi-weekly medication management and monitoring for seniors living at home or in an assisted living facility. RN oversight, administration of injectables, prescription refills and orders, MD communication, increased compliance, patient education, diabetes management, and side effect evaluation.

 

Continuum of Care

As older adults move from one end of the continuum (independence) to the other (dependence on others), our professional care managers identify each individual's changing needs and implements a plan of care that is consistent with the client's needs and goals. As their advocate, our goal is to make sure the appropriate services are in place in order to meet the presenting needs.

 

Transitional Care Program

As health professionals, we realize that our clients move in and out of areas of service need as they experience changing levels of independence and dependence. 

An example of this is when a client is discharged from a hospital or skilled nursing facility and may need in-home care services and home delivered meals for a short period of time.  We will arrange for the services, personally coach service providers, and be present during this transitional period. 

Seniors moving into a new environment also benefit from supportive care from PNP's Transitional Care Program, as this can be a frightening and challenging time in one's life.

“We are so grateful that we had Debbie, supporting our mom when we weren’t able to be there with her. She has always been there when we needed her the most. She kept us informed daily of mom’s changes and improvements and had all needed services in place by the time mom returned home from the hospital.” R.C.
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