Case Management provides services to older individuals, disabled adults and their families to assist them to access or coordinate services to keep older individuals in their home.
- Assessing needs (including the physical, psychological, and social needs of the individual)
- Developing service plans (such as hospital discharge plans)
- Coordination and monitoring service delivery (including coordination and monitoring to ensure that services specified in the plan are being provided)
- Providing follow-up and reassessment (revision of the status of the older individual, or if necessary, a primary caregiver or family member of the older individual)
- In accordance with the wishes of the older individual, advocacy for needed services or resources
- Training in medical adherence apps such as trackmystack, a medical tracker.