We will develop individualized care plans, tailored to clients’ specific needs and goals. Set achievable short-term and long-term goals.

We will advocate for the client’s rights and access to necessary services. Support clients in navigating complex systems and overcoming barriers.

We will regularly monitor clients’ progress and adjust care plans as needed. Evaluate the effectiveness of interventions and make necessary modifications.

We will provide immediate support and intervention during a crisis. Develop crisis management plans and offer emergency resources.

We will educate the clients and their families about available services, their conditions, and coping strategies. Offer emotional support and counseling to address mental health and well-being.

We will assist in planning transitions from one care setting to another, such as hospital, home or hospice.

We will maintain regular contact with clients to ensure ongoing support and address new needs. Provide long-term follow-ups as needed.

We will maintain accurate and up-to-date records of client interactions, assessments and care plans. We will ensure compliance with legal and
organizational standards for documentation.