First 30 days: 

• Current services:
  • Have they started – offering a 3 way call to home care agency if needed
• Medications: filled, understanding, concerns?
  • Special enrollment period: Is there a part D plan needing review?
• Primary Care: any appointments or trips to the ER
• Falls: cause/how many/encourage conversation with primary care or classes
• Review emergency plan: review/develop/resources needed (i.e. Personal Emergency Response System)
• Durable medical equipment: did they get anything new/do they need anything?  
• Seasonal: risks/tasks
• Additional referrals needed?
• Backup caregiver plan: what would you do if something happened to your caregiver? Has anything changed with your caregiver?

 Caregiver questions: 

• Current services for them: caregiver consultant, respite, adult day, support groups, etc.
• Are your able to get their own needs met like getting to appointments, time away, maintaining healthy eating and sleeping habits?
• Should they have their own support plan/client record?

 In-person home visit: 

• Environmental review: observation and discussion if notable concerns within CLS scope.
  • Clutter, rugs, stairs, safe exit plans, disorderly medication, concerns with pets and other.

 Semi-annual check-in questions: 

• Current services
• Has anything become more difficult?
• Falls
• Hospital/ER visits
• Medications
• Financial situation: any changes?
• Seasonal: risks/tasks
• Backup caregiver plan