Definition of Terms or Services

Advance Care Planning Documents

These are legal documents that allow you to name the person(s) you trust most to speak for you only in times when you become too sick to make medical decisions for yourself or documents that list your treatment preferences under specific health circumstances.

Care Coordination

Care coordination is the deliberate organization of patient care activities between the patient and those involved in a patient's care to facilitate the appropriate delivery of health care services.

Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care to ensure the right care at the right time and in the right place.

Coordination ensures services are in place to maintain safety and well-being while avoiding illness and/or hospitalizations.

End of Life and Palliative Care Planning

Using state regulations and working with the individual and/or family, we will collaborate on ‘must haves’ in facilitating a beautiful earthly transition as well as documents that will ease the burden on family when medical conditions become unstable and decisions need to be made.

Patient Review Instrument (PRI)

A tool that is completed by a licensed assessor that determines levels of care and is required in New York State before individuals can be admitted into a nursing home for rehabilitation or long-term care services.

Screen/PASRR or Preadmission Screening and Resident Review

A mandatory tool that is completed by a licensed assessor for the following reasons:

1. Prior to admission to a residential health care facility (RHCF).

2. A hospitalized patient who is designated as Alternate Level of Care (ALC).

3. Residents of a RHCF who are newly diagnosed with serious mental illness and/or intellectual disability/developmental disability.

4. Residents who no longer meet the categorical determinations criteria.

5. Residents of a RHCF or patients designated ALC who have been previously identified as having a serious mental illness and/or intellectual disability/developmental disability and are experiencing a significant change in physical or mental condition.