Specialized Care Programs
Three condition-specific coordination tracks with dedicated protocols, milestone tracking, and family support — because a stroke, a dementia diagnosis, or a major surgery each demands a different playbook.
Our Tracks
Three Conditions. Three Specialized Playbooks.
Each track follows a structured protocol designed around the clinical timeline of the condition — so every phase of recovery has a plan.
Dementia Care Coordination Track
Structured support for families navigating cognitive decline — from early diagnosis through advanced care.
Dementia isn't one condition — it's a progressive journey that reshapes every aspect of care. Our dementia track provides stage-appropriate coordination: early-stage planning and legal documentation, mid-stage safety and caregiver support, and late-stage facility coordination and comfort care.
Early Stage
- Cognitive baseline documentation & specialist coordination
- Legal & financial planning triage (POA, advance directives)
- Family education on diagnosis, prognosis & what to expect
- Home safety assessment with dementia-specific modifications
- Routine establishment to support cognitive function
Mid Stage
- Wandering prevention & safety monitoring coordination
- Caregiver respite scheduling & support group connection
- Medication management for cognitive & behavioral symptoms
- Daily structure & activity programming coordination
- Driving cessation & transportation alternative planning
Late/Advanced Stage
- 24/7 care coordination (in-home or facility placement)
- Palliative care & hospice coordination when appropriate
- Swallowing/nutrition specialist referrals & monitoring
- Family communication & anticipatory grief support resources
- Comfort-focused care plan development & oversight
Post-Stroke Recovery Coordination Track
The first 90 days after a stroke determine long-term outcomes. We make sure nothing is missed.
Post-stroke recovery is a race against time — and against a fragmented system. Your coordinator ensures that discharge instructions are executed, therapies are scheduled without gaps, medications are reconciled, and recovery milestones are tracked against clinical benchmarks.
Acute Phase (Hospital to Home)
- Discharge planning coordination before hospital departure
- Home setup: equipment, modifications, accessibility assessment
- Medication reconciliation — new prescriptions + existing regimen
- Family caregiver training on transfer techniques & warning signs
- First-week daily check-ins for complication monitoring
Rehabilitation Phase (Weeks 2–12)
- Physical, occupational & speech therapy scheduling — no gaps
- Insurance authorization tracking for ongoing therapy sessions
- Recovery milestone tracking against NIHSS-based benchmarks
- Secondary stroke prevention: BP monitoring, medication adherence
- Transportation coordination for therapy appointments
Long-Term Adaptation (Month 3+)
- Functional baseline reassessment & care plan adjustment
- Return-to-independence planning (driving, cooking, finances)
- Depression & cognitive screening coordination
- Caregiver burnout monitoring & respite scheduling
- Ongoing specialist follow-up calendar management
Post-Surgery Discharge Coordination Track
Surgery is planned. Complications shouldn't be. Our discharge track prevents the most common post-surgical setbacks.
A successful surgery can unravel in the days and weeks after discharge — missed follow-ups, medication errors, unrecognized infections, skipped therapy. Your coordinator builds a discharge execution plan and monitors it daily through the highest-risk window.
Pre-Surgery Preparation
- Pre-habilitation coordination (PT/OT before surgery when indicated)
- Home preparation checklist: equipment, supplies, meal prep
- Transportation plan for surgery day & all follow-ups
- Medication review: what to stop, what to continue pre-surgery
- Caregiver schedule coordination for first 2 weeks post-op
Immediate Post-Discharge (Days 1–14)
- Daily monitoring calls for pain, wound, mobility, and nutrition
- Discharge instruction translation into daily task checklist
- Medication schedule setup with refill reminders
- Infection warning sign education & escalation protocol
- Early mobility encouragement within surgical restrictions
Recovery & Return to Baseline (Weeks 3–12)
- Physical & occupational therapy scheduling and attendance tracking
- Follow-up appointment coordination with surgeon & specialists
- Recovery milestone tracking: mobility, pain, independence
- Gradual return-to-activity planning with provider guidance
- Medication tapering & discontinuation management
How It Works
Every Track Includes the Same Foundation
While the clinical protocols differ by condition, every specialized program is built on the same comprehensive coordination infrastructure.
Condition-specific clinical protocol with phase-based milestones
Master calendar with all appointments, therapies & follow-ups synced
Proactive milestone monitoring with complication flagging
Family education & support resources tailored to the condition
Your Parent's Condition Deserves a Dedicated Playbook
Every diagnosis comes with its own timeline, risks, and milestones. Let a coordinator who knows the playbook handle the logistics — so your family can focus on what matters.