Comprehensive Dementia Care Services, Built Around Your Family
Every AbleLiving patient is supported by an interdisciplinary, clinician-led care team delivering the full standard of care under Medicare's GUIDE Model — at no cost if you're eligible.
SERVICE 1
Comprehensive Assessment
& Care Plan
A clinician from our team will meet with you to fully understand health needs, cognitive and functional status, and daily life, resulting in a personalized care plan built around your goals, not a generic checklist.
An advanced practice assessment
Diagnosis confirmation and staging of dementia severity
A written, person-centered care plan shared with your existing doctors.
SERVICE 2
Care Navigation & 24/7 Access
A dedicated care navigator becomes your single point of contact, coordinating appointments, answering questions, and connecting you to community resources like transportation and meals. Round-the-clock access to a care team member or helpline.
- One named care navigator, not a rotating call center
- 24/7 phone access for urgent questions or concerns
- Coordination between your primary care doctor, specialists, and AbleLiving.
SERVICE 3
Caregiver Education, Training & Support
Family caregivers are part of the care team, not an afterthought. Direct education on managing dementia symptoms day to day, plus ongoing emotional and practical support.
- Skills training on dementia-specific behaviors and communication
- Ongoing monitoring of caregiver stress and wellbeing
- A direct line to your care team.
SERVICE 4
GUIDE Respite Services
- Qualifying caregivers get access to respite care, temporary relief through in-home respite providers, adult day centers, or 24-hour care facilities.
- Available to qualifying caregivers of moderate-to-high complexity patients
- Choose the setting that fits — home, adult day center, or facility-based
- One of GUIDE's most valuable benefits.
SERVICE 5
Ongoing Monitoring & Support
Dementia care is not a one-time assessment. Our interdisciplinary team provides ongoing monitoring, clinical follow-ups, and adjustment of the care plan as the patient's needs evolve over time.
- Regular check-ins with your care team
- Updates to your person-centered care plan
- Ongoing assessments of cognitive, functional, and health status.
SERVICE 6
Transitional Care Management
Transitions between the hospital, rehabilitation facility, and home can be overwhelming for patients with dementia and their caregivers. Our team helps coordinate care after a hospitalization or other major care transition to reduce confusion, address new needs, and support a safer return home.
- Follow-up after hospitalization, rehabilitation, or other qualifying care transitions
- Review of discharge instructions, new diagnoses, and changes in the care plan
- Coordination with your primary care provider, specialists, home health agencies, and other members of your care team
- Identification of new medical, functional, or caregiver needs following the transition
- Support with follow-up appointments, services, and community resources.
SERVICE 7
Medication Management & Reconciliation
Medication regimens can become complicated, especially when multiple doctors, specialists, pharmacies, or recent hospital stays are involved. Our care team reviews medications to help identify discrepancies, reduce confusion, and make sure everyone involved in your care is working from the same medication list.
- Review of prescription medications, over-the-counter medicines, and supplements
- Reconcile any use of high-risk medications
- Medication reconciliation after hospital stays and other care transitions
- Identification of duplicate medications, conflicting instructions, or potential medication concerns
- Coordination with your physicians, specialists, pharmacies, and caregivers when questions arise
- Education for patients and caregivers on medication schedules and changes
- An updated medication list incorporated into your ongoing care plan.