Comprehensive Care Management
At Aabcor, we provide personalized care coordination for individuals with brain injury and those facing complex care situations. Our goal is to help individuals and families navigate healthcare systems, coordinate services, and create clear care plans that support independence, safety, and quality of life.
Every situation is unique, and our services are tailored to meet the specific needs of each individual and family.
Care Assessment and Planning
Our care coordination services help individuals and families manage complex care needs by organizing services, improving communication between providers, and ensuring that care plans remain aligned with the individual’s goals.
This includes a Comprehensive Needs Assessment, followed by a Personalized Care Plan.
1) Comprehensive Needs Assessment
A Care Manager will gather information to address physical, psychological, social, environmental and functional needs.
During the visit, our care manager will ask questions and lead conversations to understand a persons current situation, risks, strengths and unmet needs. This information will guide the care planning process.
2) Personalized Care Plan
A care plan is a structured document that outlines specific services, short and long term goals , actionable steps and supports needed to address an individuals identified needs. It serves as a roadmap for coordinating care and ensuring that appropriate services are received to maintain health, safety and quality of life.
Our goal is to help create a well-organized and coordinated care approach that supports long-term stability and independence.
Ongoing Care Coordination
Some individuals may request further assistance with putting the care plan into action. Our care manager can assist with the following:
✔ Communication with caregivers and family members
✔ Identifying and arranging home care and community services
✔ Assistance navigating healthcare and disability systems
✔ Monitoring services and adjusting care plans as needs change
✔ Advocacy for the individual’s needs and preferences
✔ Coordination of therapies and rehabilitation services
✔ Support for families adjusting to life changes
✔ Development of long-term care strategies
✔ Planning transitions from hospital or rehabilitation to home
How Does it Work?
1) 15 min Discovery Call
We begin with a quick 15 minute conversation to understand your situation and determine how our services may be helpful.
This is usually performed over the phone to gather information to determine the best path for your specific circumstances.
2) Comprehensive Assessment
This assessment is performed either in-person or via online video conference. A care manager will conduct a detailed assessment of needs, supports, and goals.
The assessment can take up to 2 hours for the care manager and family to get information needed to put a personalized care plan together.
3) Personalized Care Plan
Using information gathered at the assessment and feedback, the care manager will develop a customized plan outlining services, strategies, and coordination needs.
Next, the care manager will reach out to the family to set up a time to discuss the care plan and answer any questions the family or individual may have.
This follow up visit will last up to one hour and be performed via phone or online conference call.
4) Ongoing Care Coordination (Optional)
If the family or individual is interested in setting up services outlined in their care plan, they can choose ongoing care coordination.
Their Care Manager can assist with tasks such as communicate with providers on their behalf, or implement recommended resources outlined in their care plan.
Ongoing Care Coordination can be hourly, weekly, monthly or as needed.