PrimeCare Services

A Custom Approach to Elder Care

Mass General PrimeCare is an elder care service that works closely with both elders and the family members and friends who care for them to create a coordinated and customized care plan.

Our care managers provide concrete resources, elder care plans, caregiver support, as well as resources including private home care, assisted living and nursing home options to ensure the well-being of the elder, while making it easier for caregivers to maintain a healthy balance in their lives. Depending on each individual’s needs, our services may be targeted to specific areas, such as assisted living decisions, or may be more comprehensive. One of the keys to successful care of an elder is ensuring that the caregiver can sustain the time and energy needed for his/her family, career and other life interests.

Our Comprehensive Services

At PrimeCare, our goal is to gain a full understanding of the specific issues and concerns faced by each elder and caregiver, and to provide a comprehensive, individualized care plan detailing the services and resources available to address these needs.

The plan provides step-by-step, issue-by-issue direction and guidance to help keep the elder safe, secure and as independent as possible. Included in the plan is customized guidance and recommendations for managing care costs.

Some of our clients use the plan as a guide to implement the care steps themselves. Others prefer to have PrimeCare help them carry out some or all components of the plan. In either case, PrimeCare provides the information, tools and caregiver support to best implement the plan.

What to Expect

We perform a comprehensive in-home evaluation to gain a full understanding of the situation, the needs of the elder and caregiver and any specific concerns. If the patient is not at home, our initial assessment can also take place at the acute care hospital, rehabilitation facility or any other setting along the care continuum.

Once we have created a comprehensive and individualized plan tailored to the needs of each elder and caregiver, a care manager will help navigate the health care system to ensure that your elder’s care is coordinated and effective. We will help find high-quality, cost-effective medical care solutions. The care manager will:

• Assist in scheduling appointments with primary care doctors, specialists and other providers
• Arrange for senior transportation to and from medical appointments
• Clarify and assist with the implementation of treatment plans
• Work with the elder’s doctor(s) to communicate elder-care related concerns
• Participate in family and health care provider meetings
• Provide elder and caregiver support
• Deliver education about medication and create an easy system for taking and refilling prescriptions to optimize compliance
• Provide guidance in all aspects of care for an elder with Alzheimer’s disease or related dementia

The care manager will also ensure that the home environment maximizes the elder's independence while minimizing safety risks through a home safety evaluation. This evaluation includes:

• Identifying and purchasing equipment
• Developing an emergency plan that may include home monitoring devices and emergency response systems
• Addressing concerns about elder driving ability and alternative transportation options
• Formulating a nutrition plan
• Determining the need for in-home health aides, homemakers and companions

The care manager can explain how to best obtain elder care providers for these services, as well as alternative living options. Our care teams provide guidance and support to evaluate and select living options such as assisted living, skilled nursing care, long-term care, rehabilitation settings, adult day care and respite care. We can then help implement the plan, as this can often be the most difficult step to successfully navigate.

Guidance for Financial, Legal and Insurance Matters

Meeting the rising cost of elder care services can be challenging for elders on fixed incomes and their caregivers. PrimeCare can provide information on how to maximize your financial resources for elder care, including:

• The benefits and coverage of health insurance plans and long-term insurance plans
• Elder community resources including The Ride and Senior Shuttle, as well as private home care agencies
• Cost-effective, high-quality options, such as equipment purchases and home care

Our care managers can also provide guidance on estate planning, health care proxies, advance directives, power of attorney and long-term care insurance.

Caregiver Support

Our care managers provide elder support in a range of ways, including onsite visits to the elder's home or current residence. These visits evaluate the care your elder is receiving, which can be particularly helpful if your elder lives far away. Care managers can also assist in arranging placement or transfer to select facilities, as well as participate in healthcare provider meetings, communicating between the medical team and the family. In all capacities, the care managers serve as advocates for each elder.

Our Geriatric Assessment Service evaluation is used to determine:

• Medical history, including providers, medication and elder care needs
• Cognitive status
• Nutrition and dietary status
• Social and psychological well-being
• Home safety
• Financial and legal planning, insurance coverage
• Caregiver support and needs