Case Management

At PNW Aging, our Case Management services begin with a comprehensive Care Assessment conducted by a social worker. This assessment gives us a full picture of the client's health, safety, environment, legal standing, and social needs. The result is a clear, actionable Care Plan, tailored to the individual and ready to share with family, guardians, or legal representatives. Our team doesn’t just recommend solutions—we help make them happen.

  • What’s Included in the Care Assessment:

    - Review of medical conditions, medications, and healthcare providers

    - Evaluation of mobility, fall risk, and home safety

    - Cognitive (SLUMS) and emotional health screening

    - Review of personal care needs, including ADLs and IADLs

    - Assessment of social engagement and support network

    - Review of legal documents such as POA, DNR, Advance Directive

    - Identification of values, cultural preferences, housing goals, and emergency preparedness

  • What You’ll Receive:

    - A professional Care Plan PDF outlining concerns, goals, barriers, and recommendations

    - A tool designed to guide guardians, conservators, families, and care teams

    - A clear action plan that serves as the foundation for our ongoing work together

  • Ongoing Case Management Services:

    - Our greatest value comes from putting the plan into motion. With ongoing support, we help coordinate care, navigate systems, and adapt to changing needs. Services include:

    - Attending and coordinating medical appointments

    - Communicating with doctors, caregivers, Guardians, Conservators, POAs

    - Crisis management and hospital advocacy

    - Support with transitions, facility tours, and placement

    - Referrals to trusted professionals and resources

    - Regular check-ins and updates to the care plan

  • Ideal For:

    - Guardians or conservators who need structure and follow-through

    - Families wanting expert guidance and long-term coordination

    - Attorneys, fiduciaries, or healthcare providers seeking a social work partner

  • How It Works:

    - Schedule a Care Assessment with our team

    - Receive a customized Care Plan with professional recommendations

    - Move forward with ongoing support, and let us help implement and update the plan over time

Frequently Asked Questions:

  • Case management is a professional service that helps older adults and their families navigate aging-related challenges. It includes assessment, planning, coordination, and advocacy.

  • The Care Plan outlines medical, social, legal, environmental, and personal needs. It includes concerns, barriers, goals, and professional recommendations.

  • No, but we strongly recommend it. While the Care Plan is valuable on its own, most clients find the greatest benefit in having our team help implement those recommendations and adapt the plan as needs evolve.

  • No. Case management focuses on planning, coordination, and advocacy. We often work with caregivers but do not provide hands-on personal care as part of this service.