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Aging in Place


From Assessment to Care Plan-What to expect

The goal of our ‘Aging in Place’ program is to relieve some of the stress that families experience, as they care for their aging parents.  We work towards enhancing the lives of our aging clients and allowing them to be as independent as possible for as long as possible. Families can feel good about the way we provide our services- with compassion, care and sensitivity.

In order to help you better understand what we do, below is a breakdown of our services:

Once a client (adult child or elderly individual) initiates service from our Aging in Place program, one of our Geriatric Social Workers schedules a home visit with the aging client (& spouse) to do a comprehensive assessment.  The assessment will include the following areas:

-cognitive functioning
-emotional state
-physical health
-medication management
-nutritional status
-environmental conditions and safety
-activities of daily living (ADL’S)
-financial issues
-socialization
-family history & current relationships

We gather most of our information from observation and from the elderly client(s), but will often consult with family members to supplement the information or if the client is unable to communicate accurately.  However, we encourage our aging clients, when appropriate, to be as involved as possible in helping us understand their issues and in making decisions about their care.  


Following the assessment phase, the social worker will then create individualized care plan recommendations to address each area of concern.   These will include specific referrals for appropriate services and suggestions for addressing each of the client’s unique needs.  The social worker will contact the aging client and/or the adult child(ren) to review and discuss the assessment and the care plan recommendations.  They will also receive a written copy of the recommendations.   

The adult child and/or aging client may choose, at this point, to implement the recommendations themselves and follow-up on the various suggestions. If the client and adult child are so inclined, we can continue with our services by facilitating the implementation of the care plan and advocating for the client.  We will consult with the clients’ doctors, work with other caregivers, help apply for federal or county entitlements, arrange for home care, arrange for bill paying services, link clients to other community services and much more.  We do all of this while providing support to the client, working at a pace he/she can tolerate and helping him/her deal with any changes.  Once the supports are in place, we will make home visits to monitor the client’s progress and intervene, when appropriate, to help prevent crises.  Throughout this process, we communicate regularly with the adult children or other involved relatives to update them and discuss any concerns.  We know how important family is and we do all we can to support family members and involve them in their loved one’s care. 

To receive additional information and discuss a fee schedule contact JF&CS 732-774-6886.

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