• Case management services and options counseling • Supported housing, group homes, and assisted living facilities • In-home aide services (for personal care, chores, other (activities of daily living) • In-home emergency response system • Home delivered meals, group dining programs, and grocery delivery services • Adult day care programs and senior centers • Prescription delivery services or supports • Assistance with medical equipment, supplies, or non-emergency medical transportation • Assistive technology and home modifications • Peer supports and independent living skills training • Informal or professional assistance with money management • Assistance with personal needs from family, friends, and others in the patient’s community (check-ins, errand running, reminders, transportation to appointments or stores, etc.) The availability of options depends on the patient’s needs, location, Medicare/Medicaid eligibility, and other factors. Support planners, service coordinators, local
Departments of Social Services, and Area Agencies on Aging offices can help assess needs and identify appropriate community resources. Options counseling may also be available to Medicare beneficiaries through the State Health Insurance Assistance Program (SHIP) and to Medicaid beneficiaries through Maryland Access Point (MAP). Ensure the patient has access to any needed supports and accommodations (see Appendix A ), including effective communication supports, when explaining their rights. Advise them on what to expect during the discharge process and what is needed to address their needs. Include those who know the patient best in discussions about potential services as appropriate. With education and support, the patient, family members, and other loved ones can assist in addressing barriers or needs. This may require multiple meetings, additional time for services and supports to be put in place, and de-escalating potential tensions between the patient, family, friends, support persons, or staff. When conflicts or care planning become an issue, consider mediation (discussed below) to help refocus everyone involved on shared goals for the patient.
IDEAL
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