Use a case management model for frail elderly patients living independently, coordinating aspects of long-term care (LTC) such as status assessment, monitoring, advocacy, care planning, etc.
Support a collaborative approach by a multidisciplinary team of professionals working to meet the full range of long-term care (LTC) needs for frail elderly patients living in community settings
Provide culturally sensitive assistance and care coordination, and guide patients through available medical, insurance, and social support; also called systems navigators