Horizon Home Care & Hospice, Inc. will optimize health and quality of life for patients and families in the home and other settings. Our clinical experience, relationship-centered care and respect for patient rights set us apart as the region's employer and provider of choice.

Our philosophy of compassion and responsiveness extends from our employees to our hospital sponsors and physicians, and to the patients and families we are privileged to serve.

Assesses older adults, develops a comprehensive plan of service options to meet the needs of older adults and provides on-going management as appropriate to the needs of the patient and their family.

• Interviews older adults and caregivers in their place of residence or office setting to obtain information about the health and functional status, cognitive and psychological functioning, interpersonal relationships, financial and social needs and home environment.
• Develops and implements a comprehensive plan of care to address the needs and objectives of the patient and family. Updates care plan as required
• Documents concisely all assessments, treatment plans and ongoing monitoring and evaluation of patients.
• Maintains timely records of all contacts with patients and family members and completes required documents for appropriate billing of services.
• Provides verbal and written communication to other providers involved in patient's care.
• Coordinates health care and all applicable in-home services. Acts as a broker in arranging/monitoring of any other type of service.
• Maintains broad knowledge of community services and appropriately refers patients and their family members.
• Participates in interdisciplinary conferences on behalf of patient.
• Responsible for networking, educating and relationship-building with current and potential referral sources.
• Provide "on call" coverage during nonbusiness hours to geriatric care management patients.

#socialwork