A Team Approach to Care

• Board-certified physicians with experience navigating complex medical histories.    
   
• Nurse practitioners and physician assistants trained in assessing multiple comorbidities.   
      
• Registered nurses as case managers focused solely on patients’ needs and goals.
  
  
• Social workers who evaluate root causes of health challenges and facilitate access to resources.    
        
• Physical and occupational therapists for recommendations regarding assistive devices, home modifications, and fall risk reduction.       
   
• Nutritionists to ensure dietary requirements for medical conditions and disabilities are met.
  
  
• Mental health professionals promote emotional well-being amid life’s adversities.   

Holistic Assessments         

• In-depth reviews of patients’ medical histories, medications, allergies, and laboratory results.      
  
  
• Evaluations of physical, cognitive, and sensory impairments restricting daily activities and independence.  
  
  
• Screenings for mental health diagnoses like anxiety, depression, and substance use that impact health.       
  
  
• Assessments of social determinants of health including housing, finances, transportation, and caregiver support.      

Comprehensive Care Plans    

• Individualized goals based on patients’ priorities for safety, comfort, and quality of life.
  
  
• Strategies to simplify complex medication regimes and minimize side effects and drug interactions.
  
  
• Treatment plans for managing multiple comorbidities simultaneously that patients and caregivers can understand.
  
  
• Schedules for monitoring by primary care physicians, medical specialists, and home health clinicians. 
       
• Recommendations for community services, resources, and devices to facilitate the highest level of function possible.      

Coordination of Care       

• Referrals to specialists for conditions beyond primary care expertise. 
     
• Access to home health services including nursing, personal care, therapies, and medical equipment.      
  
  
• Psychosocial interventions including counseling, support groups, adult day programs, and meal deliveries.   
  
  
• Connections to long-term care facilities when in-home support becomes too intensive.     
        
• Transitions between inpatient and outpatient settings to ensure appropriate follow-up and complication management.
  
  
• Communication among the entire care team from physicians to nurses to social workers and more.           

Compassionate Advocacy         

• Empower patients and caregivers to participate in medical decision-making and self-management. 
     
• Validate challenges associated with navigating a complex medical situation.     
     
• Respect goals and preferences for safety, comfort, and dignity above all else.   
    
• Intervene on behalf of patients to ensure needs are heard, barriers addressed and care optimized.     
  
  
• Act as a trusted resource for education, referrals, advice, and emotional support along the healthcare journey.      

If you’re coping with multiple medical conditions, physical limitations, social difficulties, or special needs – and could benefit from having an entire team focused solely on optimizing your care – please contact us. Our mission is simple yet profound: to provide the most comprehensive, personalized support possible so you can live your best life, by your definition.