Care Management : Project Continuum: CARE

Project Continuum CARE (Coordinating Care for At-Risk Elderly) is Funded by the Kate B. Reynolds Charitable Trust.

PCC serves patients age 75 and older who are in hospital or rehabilitation, and meet risk-screening criteria, which include: living alone, poly-pharmacy, lack of identified caregiver, dementia/other cognitive impairment, fall history, and frequent hospital use.

PCC was developed in recognition that transitions, in addition to hospitalizations, represent risk for the health and well-being of older adults, especially those over age 75. The Care Manager serves as a transitions navigator for at-risk patients across the continuum of care by providing ongoing care management services, establishing  a case review schedule and mechanism for rapid response communication when problems arise, and providing a comprehensive assessment of client and caregiver needs.

A patient and family counseling support service (Peer and Professional Counseling) in collaboration with All Souls Counseling Center, addresses mental health needs during transitions in care. This service will help patients and caregivers maximize personal resources to adjust to changes in health status or transitions in level of care.

Contact  Kate Zurich at the Council on Aging 277-8288 with questions or for more information.