Research shows the critical elements of care are as follows:
- A single point person, a nurse, social worker or advocate, to assess and coordinate the overall care of a senior.
- A comprehensive, holistic assessment of each senior’s priorities, needs, goals and preferences.
- A multidiscipline collaboration between seniors, family caregivers, doctors, advocates and other team members to implement a streamlined plan of care designed to promote positive health and cost outcomes
- An advocate that provides frequent support to a senior by making regular home visits and communicating daily by telephone.
- An advocate to ensure a senior’s continuity of healthcare by accompanying seniors to medical and doctors’ appointments.
- An advocate who can actively engage a senior and their family to join together to meet the senior’s overall goals.
- An advocate who can develop a close enough relationship with the senior to quickly identify and respond to changes in their health status so medical concerns can be rapidly addressed to avoid an unnecessary crisis or hospitalization.
- An advocate who is able to develop a strong working relationship between all members of a senior’s team to trouble-shoot and develop plans for the future.
- A plan that is entirely focused on the senior and the family caregiver and driven by a commitment to create and sustain an enduring, continuous, trusting and healing relationship among and between seniors, patients, family caregivers and the advocate.