Geriatric Care Management
Assessment & Planning
In-Home & Wellness Support
Assessment & Planning
Personalized Needs Assessments –
In-depth evaluations of health, cognition, home life & collateral supports.
Individualized Care Plans – Customized plans aligned with physician goals, client values & family concerns.
ADL & IADL Evaluations – Measuring independence with daily living skills.
Memory & Dementia Care – Specialized assessments, care planning & family education.
Care Coordination
In-Home & Wellness Support
Assessment & Planning
Medical Appointment Coordination – Scheduling & communication.
Liaison between Care Teams – Serving as the central hub between doctors, therapists, discharge planners & families.
Referrals to Trusted Providers – Home care specialists, fiduciary/trust services, legal/financial advisors, et cetera
Advocacy & Health Education – Helping families understand care options, benefits, & self-management strategies.
In-Home & Wellness Support
In-Home & Wellness Support
Specialized Health Management
- Nursing & in-home caregivers.
- Caregiver respite & companionship programs
- Meals Coordination- Meal planning, grocery delivery, favorite comforting foods;
- Incontinence supplies, home medical equipment.
- Para-medical transport for safe access to appointments and activities.
Specialized Health Management
Specialized Health Management
Specialized Health Management
- Diabetes and insulin management
- OT/PT, speech therapy/s
- Home dialysis.
- Stroke-related complication support and recovery.
- Rehabilitation following surgery, accident, and/or injury.
- Custom mobility solutions such as electric wheelchairs, lifts, and adaptive equipment.
Ongoing Support & Monitoring
Specialized Health Management
Palliative & End-of-Life Care
- Regular check-ins to adapt care plans as needs change.
- Assist with crisis intervention, rehabilitative care, assisted living.
- Support with hospice transitions
- Ongoing documentation and outcome tracking to ensure consistent, quality care.
- Emotional support, therapy referrals, holistic care planning & family disease education.
- Social connection and companionship resources.
Palliative & End-of-Life Care
Specialized Health Management
Palliative & End-of-Life Care
- Advance care planning, POLST, DPOA, legal/medical decision.
- Palliative and hospice support focused on comfort and dignity.
- Bereavement resources for families coping with loss.
- Assistance with final wishes, burial & funeral services, transfer of remains & organ/tissue donation.
Individualized Geriatric Care
Our high-caliber care managers take the time to get to know our clients and approach the care plan from a holistic vantage point. At Older Oak, we provide comprehensive, personalized care coordination for older adults and their families, ensuring dignity, independence, and quality of life. We believe every elder deserves a compassionate advocate who helps navigate complex medical, social, and emotional needs with respect and cultural sensitivity.
Attentive, experienced care management combined with effective stratification and comprehensive patient data separates an average care management program from a superior program.
Our care management process has four core principles. When implemented properly, these principles help protect clients and patients and make our services and interventions more impactful:
- Building trusting relationships
- Empowering our clients
- Using evidence based interventions
- Leverage technology.
Huckleberry Consulting
In 1800s slang, the phrase, “ I’m your Huckleberry” was used to indicate someone was the right person for a task. At Older Oak, we aspire is to be the Huckleberry to your family’s most complex aging needs.
Ask your Care Management/Huckleberry Consultant for help with…
- Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits.
- Conducts assessments to identify barriers and opportunities for intervention.
- Develops care plans that align with the physicians treatment plans and recommends interventions that align with proposed goals.
- Generates referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement and maintenance of successful health outcomes.
- Liaise between service providers such as doctors, social workers, discharge planners, and community-based service providers to ensure care is coordinated and care needs are adequately addressed.
- Coordinates and facilitates with the multidisciplinary healthcare team as necessary to ensure care plan goals and treatment is person-centered and maximizes member health outcomes.
- Assists in identifying opportunities for alternative care options based on member needs and assessments.
- Evaluates service authorizations to ensure alignment and execution of the members care and physician treatment plan.
- Contributes to corporate goals through ongoing execution of member care plans and member goal achievement.
- Documents all encounters with providers, members, and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates care plans based on member needs, as appropriate.
- Occasional overtime as necessary.
- Additional duties as assigned.
Palliative Care
Compassionate Guidance for Palliative Care
We guide older adults and families through the journey of aging with dignity, independence, and peace of mind. We begin with comprehensive assessments to understand health, cognition, daily living, and support systems, then create personalized care plans that align with physician goals and client values. As needs change, we provide ongoing coordination—scheduling appointments, connecting with providers, and serving as the central liaison between medical teams, community resources, and families.
Our services extend well beyond medical management. We coordinate in-home support such as nursing assistance, therapy services, meal and supply delivery, caregiver respite, and companionship programs. We specialize in managing complex health needs—including diabetes, kidney disease with home dialysis, stroke recovery, and rehabilitation after surgery or injury—while ensuring emotional and social wellbeing remain central to every plan. Through regular monitoring, crisis support, and outcome tracking, we ensure care remains seamless, adaptive, and dependable.
End of Life Planning
End of Life & Hospice Care
We help families with advance care planning, POLST, powers of attorney, last will and testaments, hospice support, funeral arrangements, and the transportation of last remains. We also provide options for organ and tissue donation, or donation for scientific research for rare disease. With bereavement resources and emotional support for loved ones, we ensure families are cared for with compassion, and respect at every stage of life.
Additional Information Available on Resources on Aging
