Our Nurse Care Management Process

Ambient Aging offers a wide range of services and support, and our Concierge Nurse Care Management Service is a comprehensive and highly personalized process designed to meet your evolving needs with collaboration, compassion, and clarity. This model provides in-depth, ongoing support for individuals who require comprehensive care coordination and personalized guidance. 

Below is an example of how Ambient Aging’s concierge service is approached. 

Step 1: Assessment

We begin by meeting with you and your family in your home, taking time to listen, connect, and truly understand who you are. This visit allows us to learn about your current circumstances and gather important medical and personal history.

We explore the following areas of your life to form a comprehensive picture of your needs:

• Medical – current diagnoses, medications, and providers
• Cognitive & Behavioral – memory, mood, and emotional well-being
• Environment – home safety and accessibility
• Safety – fall risk, emergency preparedness, and abuse prevention
• Legal – presence of advance directives, powers of attorney, or guardianship
• Spiritual & Cultural – values, beliefs, and traditions that guide your care
• Functional – ability to perform daily activities and maintain independence
• Social – support network, relationships, and engagement in the community
• End-of-Life – preferences, planning, and preparation for future care

Step 2: Identification

During the initial assessment, we take the time to understand your story, identify potential barriers to progress, and help you clarify what matters most. Whether you come to us with clear goals or feel overwhelmed by medical or family challenges, we are here to help.

Some individuals face multiple barriers, including complex medical situations, unique family dynamics, financial concerns, or unclear legal needs. Based on our findings, we also recommend additional goals to enhance your quality of life and overall sense of well-being.

Step 3: Planning

With your goals in mind, we create a customized written Plan of Care that outlines:

• Identified barriers, needs, and concerns
• Recommendations and strategies for improvements in your daily life
• Referrals to trusted professionals and services to help reach your goals

We only recommend individuals and organizations we would trust with our own loved ones. After the Plan of Care is completed, you will be included in the review of the plan, and adjustments will be made based on your preferences and feedback. This plan belongs to you—your values and care needs shape it.

Step 4: Implementation

Once you approve the Plan of Care, Ambient Aging begins implementing it alongside you. We will:

• Contact and coordinate with approved specialists or service providers
• Vet and introduce any new services or professionals to ensure a good match
• Order necessary medical equipment or supplies
• Assist with scheduling appointments and arranging transportation
• Attend medical appointments to advocate, ask the right questions, and explain complex information given to you by your providers in clear, everyday language, so you understand your condition and choices.

We understand that health encompasses more than just medical aspects. Our team also supports you in areas that may fall outside traditional healthcare—family relationships, home management, spiritual beliefs, and life transitions all shape your overall wellness. We are here to help with everything. 

Step 5: Evaluation

Your Plan of Care is not set in stone—it evolves with you. Throughout the process, we check in regularly with you and your support team to ensure that your care is progressing in a direction that feels right to you.

As your needs or goals change, we will adjust the plan accordingly. This ongoing evaluation ensures that the care you receive is meaningful, responsive, and aligned with what matters most to you.

Flexible Support Options

While the process above reflects our Concierge Nurse Care Management model, Ambient Aging also offers flexible, modified services designed to support families who may not need ongoing care management but still want expert guidance during key moments of change.

For those seeking targeted support, we offer à la carte services as well as tailor-made programs tailored to your needs. These services may look like:

• One-time consultations to address specific medical, behavioral, or logistical challenges to determining long-term needs
• Family education and coaching to support caregiving barriers and needs, medical decision-making, progressive disease, and troubleshooting financial barriers, and navigating complex relational situations
• Guidance during transitions, such as post-hospital recovery, new diagnoses, or changes in prognosis
• Welfare visits and medical advocacy for families who live out of the area and would like regular visits, a professional to advocate at appointments, and email/phone call updates on their loved one
• Collaborative medical care planning for legal teams, professional guardians, and estate planners who require expert input and oversight to ensure care plans are clinically sound, realistic, and in alignment with the client’s needs and wishes
• *Housing transitions, when remaining safely at home is no longer possible

*Although we occasionally assist with housing transitions, this is not our primary focus. Our goal is always to help people age well—ideally in the comfort of their own homes, where they are surrounded by familiarity, independence, and the support they need. When a move is necessary, due to safety concerns or increased care needs, we step in to help families navigate the process thoughtfully and with integrity.

Unlike many “free” senior placement services, which are funded through referral fees from housing facilities, we do not receive compensation from any home or community. We work for you —our client—so our guidance remains objective, personalized, and solely focused on your best interests. We never pressure families into a decision for financial reasons. Every option we present is carefully vetted with your values, care needs, and financial situation in mind.

Whether you’re seeking full care management or need help with a specific concern, Ambient Aging is here to provide honest, compassionate, and expert support every step of the way.