Integrative Elder Care RN

Zoe Moffitt, RN-BC

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​​​​​​​​Services We Offer:

Care Management and Planning for Home Care and Transitions in Care:

  • Consultation for options that allow the elder to live the best possible life at home or in other settings, giving written recommendations for support and additional services - this can be a short term contract to make plans in a changing life situation or ongoing care coordination over time
  • Comprehensive Initial Assessment of elder's personal and medical history, current concerns, community and financial resources and the elder's wishes and priorities in life with written summary with specific individualized recommendations
  • Home Safety Assessment and recommendations
  • Collaborating with and assisting discharge planning from sub-acute, rehab stay or hospital
  • Care Plan development with regular and as-needed updates 
  • Regular home visits, more frequent during periods of adjustment and as needed in developing situations and in the orientation of elder and care partners to new regimens or other needs
  • Referrals when needed to geriatricians and medical specialists, financial professionals, nutritionists, support groups, and other therapists according to the elder's specific needs and preferences
  • Coordination of home care, building a team to support optimal well-being, physical and emotional health, a comfortable environment, satisfying foods, accomodations and comfort measures and 
  • Liaison between elders, physicians and other providers, with report to family or significant others
  • Phone consultation for long-distance family and all involved in care transitions to answer questions, review options,  share knowledge, and discuss the care 
  • Education and coaching for clarifying goals, understanding medical treatment and lifestyle plans
  • Medication management and review, set up and pouring medications, communication with pharmacy and providers for renewals, monitoring check-in's with care partner or elder 


Ongoing Care Coordination, Advocacy and Follow Up of the Care Plan:

  • Accompany elder to physician and other appointments with reports and consultation with family 
  • Regular visits with reassessment of needs with recommendations and care plan updates​, with written reports monthly or more frequently, and telephone or e-mail communication as needed
  • Review of care delivery and coaching for care partners in handling new care needs and difficult behaviors, and assessing any developing situation
  • Research practical solutions for issues that may arise for the elder, family and care partners
  • Advocacy for elder in a hospital stay, emergency room, diagnostic tests or clinical trials visits 
  • Phone availability to care partners, family and as liaison with physician and other providers
  • Arrangement for attendance at social events, visits from friends and outside activities 
  • Continue to creatively explore activities that support favorite activities, looking for creative solutions that bring interest and enjoyment to the elder within the home and with possibilities for outside excursions and visits
  • Coach care partners to help elders with reading, looking at art and film, finding and playing the particular music that the elder enjoys, assisting with arts, crafts and other home activities
  • Household cash management for care partners and housekeepers

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 Referrals:

  • Elderlaw attorneys for present  concerns and long term planning 
  • Assistance with moving, home organization, consolidation, 
  • Firms and individuals to complete home modifications
  • Assistance with insurance claims and home bill processing
  • Licensed therapists in music therapy, physical and occupational therapy, massage, psychotherapy
  • Clergy or faith community visitors of elder's preference​ and cultural tradition
  • Personal assistance and bookkeeping 


 Individual and group practices arranged:

  • Reiki
  • ​Yoga, Chair Yoga
  • Massage and M Technique hand massage
  • Clinical Meditation and Guided Imagery 
  • Integrative Nurse Health Coaching
  • Recreational therapy and support for social activity


 Payments and Fees:

  • Some insurances pay for home assessments, although most care management is paid privately
  • Services are billed hourly, in fifteen minute increments, or for some events, in predetermined flat rates, and billing is sent bi-monthly or monthly
  • Services for home care agencies, therapists and other professionals are billed directly to the financially responsible person or agent