Elder Medical Care: Support & Resources for the Seriously Ill

December 6, 2019, Elder Medical Care, Gilchrist
support and resources, elder medical care
(l to r) Cathy Hofmann, Jean Jacobs and Amy Hewat provide support and resources for Gilchrist’s Elder Medical Care patients and families.

Through Gilchrist’s Elder Medical Care program, social workers and resource coordinators provide ongoing emotional support and resources at no cost to patients and families facing a serious illness. Our support is intended to help families who need guidance and assistance in coping, care coordination and planning for the future.

Many of the Elder Medical Care patients receiving social work assistance and resource coordination also receive primary medical care at home from a Gilchrist nurse practitioner or physician. The team works closely together in supporting our patients and families.

The social worker is a master’s-prepared licensed clinician who provides emotional support, aids in coping skills, and assists families in working through challenges. The social worker can also assist in advance care planning, such as completing advance directives and deciding on medical interventions.

Safety planning is another role of the social worker, as many patients realize they require more help in their homes as their illness progresses. Additionally, the social worker can discuss requirements for the hospice program and assist families in evaluating when it is time to transition to hospice care.

The resource coordinator is a skilled navigator of the services available in the community and through government agencies, such as the Department of Aging and the Department of Social Services. The resource coordinator can discuss the criteria for assistance programs with families and provide hands-on guidance in the application process.

The resource coordinator and social workers can also assist a family in navigating long-term care should the need arise. Our team fulfills an important role in navigating a complex system.

The social worker generally establishes care with a visit to the patient’s home or a phone call to learn about the patient and family and find out what is most important to them. From this conversation, the social worker may make a referral to the resource coordinator if the need is present.

The social worker, with the help of a Gilchrist volunteer or intern, makes monthly calls to the patient or caregiver to evaluate the patient’s status and provide ongoing support. Families and patients are also encouraged to call the social worker if challenges surface and guidance is needed.

As social workers and resource coordinators in the Elder Medical Care at Home program, we serve an important role for patients and families as they navigate illness with ongoing challenges and needs that arise along their journey.

To learn more about Gilchrist’s Elder Medical Care program, visit

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