For Providers & Professionals

A clinical partner you can refer to with confidence.

You already do everything you can in the time you have with your patients. We step in where your visits end, providing licensed, assessment-driven geriatric care management that closes care gaps, reduces readmissions, and gives your most complex older adults the ongoing coordination they need between appointments.

Licensed RN · GCM Clinical Staff
Comprehensive Geriatric Assessment
Medication Reconciliation Protocol
Coleman Care Transitions Model
Validated Caregiver Assessment
HIPAA-Compliant Reporting
Licensed RN · GCM Clinical Staff
Comprehensive Geriatric Assessment
Medication Reconciliation Protocol
Coleman Care Transitions Model
Validated Caregiver Assessment
HIPAA-Compliant Reporting

Who partners with AskVanessa

We work alongside your team as an interprofessional partner, providing the sustained community-based support your complex older adult patients need between clinical visits. Every referral is different, and we treat each one with the attention it deserves.

Hospital Discharge Planners & Social Workers
Primary Care Physicians & Geriatricians
Hospice & Palliative Care Teams
Elder Law Attorneys & Fiduciaries
Home Health Agencies & Care Coordinators
Memory Care Specialists & Neurologists
Clinical Use Cases

Your Patient's Journey

Here is how we support your patients after you refer them. Each scenario walks you through the care they receive, who is responsible at each step, and the outcomes you can expect, from the first call through ongoing follow-up.

Clinical · Behavioral Health

Proactive Quality of Life Intervention & Psychosocial Care Management

Referral Trigger

Post-assessment flags of social isolation, low affect, or behavioral health gap in a high-risk older adult, without acute psychiatric indication.

  1. 1
    Quality of Life & Psychosocial Assessment

    GCM administers validated well-being instruments to establish a baseline across physical, psychological, social, and spiritual domains, going beyond the clinical snapshot to understand the whole person.

    GCM Lead
  2. 2
    Individualized Care Plan Development

    Life-history and preference-based interviewing informs a meaningful engagement plan. Goals are framed around what brings the member purpose, connection, and joy, not a generic activity checklist.

    GCM Lead
  3. 3
    Case Assistant Coordination

    GCM supports the family in hiring and orienting a Case Assistant who follows the care plan, accompanying the member to outings, family events, and personally meaningful activities.

    GCM + Family
  4. 4
    Monthly Monitoring & Written Status Report

    Progress tracked against established goals. Formal written report issued to the referring provider and client representative, documenting goal attainment, emerging concerns, and plan modifications.

    GCM → Referring Provider
Clinical · End of Life

End-of-Life Care Coordination & Interprofessional Family Advocacy

Referral Trigger

Terminal diagnosis with complex family dynamics, advance directive gaps, or an uncoordinated hospice or palliative transition that requires a dedicated care coordinator.

  1. 1
    Holistic Assessment & Advance Directive Review

    GCM conducts a comprehensive psychosocial and health assessment. Advance directives (POLST, DNR, healthcare proxy) reviewed and documented. Caregiver readiness and grief stage evaluated.

    GCM Lead
  2. 2
    Goals of Care Planning with the Family

    Care plan guides the family through the trajectory of terminal illness, incorporating cultural, spiritual, and bereavement support pathways. Legacy work and closure goals established with the member and adult children.

    GCM Lead
  3. 3
    Interprofessional Team Consultation

    GCM participates in family care conferences using structured communication frameworks. Coordinates with the hospice team, palliative physician, chaplain, and elder law attorney as indicated.

    GCM + Hospice + Palliative + Legal
  4. 4
    Family Advocacy, Education & Ongoing Support

    GCM ensures the member's stated wishes remain central in all decision-making. Provides the family with clear, plain-language guidance on what to expect and what to do at each stage.

    GCM + Family
  5. 5
    Monthly Status Reporting & Bereavement Pathway

    Written updates to all client representatives on a monthly or event-triggered basis. Bereavement follow-up pathway initiated after the member's death.

    GCM → All Representatives
Clinical · Medication Safety

Post-Discharge Medication Reconciliation & Polypharmacy Management

Referral Trigger

Complex post-discharge medication regimen in an older adult with polypharmacy risk, low health literacy, or a caregiver with insufficient training to safely manage administration.

  1. 1
    Comprehensive Medication Reconciliation

    Licensed RN compiles a complete medication list (prescriptions, OTCs, supplements, PRN) and reviews it with the prescribing physician and pharmacist. Potentially inappropriate medications, drug interactions, and deprescribing opportunities identified.

    Licensed RN + Physician + Pharmacist
  2. 2
    Medication Setup & Caregiver Education

    Organized pill system established based on the member's cognitive and functional status. Teach-back method confirms the caregiver understands dosing, side effects, and what to watch for. Plain-language written instructions provided.

    Licensed RN + Caregiver
  3. 3
    Adherence Monitoring & Adverse Event Surveillance

    Scheduled visits and telehealth check-ins observe administration technique. Clinical team monitors for falls risk, orthostatic hypotension, confusion, and other medication-related adverse events. Adherence formally assessed at 30 days.

    GCM + Licensed RN
  4. 4
    Monthly Medication Safety Report

    Formal report to the family and client representatives documenting regimen status, adherence, and any adverse events. Deprescribing opportunities communicated to the prescribing physician.

    GCM → Family + Referring Provider
Operational · Transitions

Coordinated Hospital-to-Home Transition & Readmission Prevention

Referral Trigger

High-risk discharge to home with caregiver capacity concerns, complex post-acute care needs, or a prior 30-day readmission in the patient's history.

  1. 1
    Pre-Discharge Coordination with the Hospital Team

    GCM coordinates with the discharge planner before discharge day, reviewing the plan, identifying gaps in caregiver capacity or home safety, and ensuring the environment is ready to receive the patient.

    GCM + Hospital Discharge Planner
  2. 2
    Four-Pillar Transition Implementation

    Medication self-management verified. Patient health record confirmed in the patient and caregiver's hands. All follow-up appointments scheduled within seven days. Written and verbal red-flag education delivered to the caregiver before discharge.

    GCM + Licensed RN
  3. 3
    Community Rehabilitation & Support Coordination

    Home health services arranged per post-discharge orders. Supplemental in-home caregiving coordinated for ADL support during recovery. Caregiver strain screened, with respite arranged if threshold is met.

    GCM + Home Health + Care Providers
  4. 4
    Structured Post-Discharge Monitoring

    Mandatory check-ins at 24 hours, 72 hours, and Day 7. Changes in condition, falls, or medication concerns escalated immediately. GCM team available on call throughout the 30-day high-risk window.

    GCM, On-Call
  5. 5
    Monthly Transition Status Report

    Written report to client representatives documenting recovery trajectory, care plan adjustments, and any escalations. Shared with the referring provider upon request.

    GCM → All Representatives
Operational · Caregiver Support

Caregiver Burnout Risk Detection & Proactive Intervention

Referral Trigger

Caregiver strain identified during a clinical encounter, or a proactive referral for a high-burden caregiver managing a patient with a progressive disease trajectory.

  1. 1
    Validated Caregiver Assessment

    GCM administers a structured, multi-domain caregiver assessment measuring burden, depression risk, social support, respite access, physical health, and financial strain. This goes well beyond a clinical impression of how the caregiver "seems."

    GCM Lead
  2. 2
    Risk Stratification & Care Plan Review

    Assessment data is entered into our monitoring system. High-burden cases trigger a clinical review by the GCM and Case Manager/Director, who determine the appropriate intervention level and activate a response plan.

    GCM + Case Manager/Director
  3. 3
    Multi-Modal Caregiver Support Intervention

    Respite care arranged (in-home, adult day program, or short-term residential as appropriate). Caregiver connected to support group, counseling, or evidence-based education program. Care plan restructured to reduce caregiver task burden through supplemental professional services.

    GCM + Community Resources
  4. 4
    30-Day Reassessment & Longitudinal Documentation

    Caregiver formally reassessed at Day 30 to measure whether the intervention is working. All assessment data, alerts, interventions, and outcomes documented in the longitudinal care record.

    GCM Lead
Administrative · Financial

Fiduciary Bill Management & Elder Financial Oversight

Referral Trigger

Client representative unable to manage an aging client's financial affairs, or elder financial exploitation risk identified that requires structured, documented oversight.

  1. 1
    Billing Centralization & Financial Protection Screening

    Fiscal Manager establishes a master bill register and redirects all creditor billing to the agency's designated address. Financial protection protocols applied from day one, with billing anomalies flagged immediately for review.

    Fiscal Manager
  2. 2
    Timely Payment & Transaction Ledger

    All authorized invoices paid within the monthly billing cycle. Full transaction ledger maintained with receipts and documentation supporting every payment.

    Fiscal Manager
  3. 3
    Monthly Bank Reconciliation & Anomaly Surveillance

    Every transaction cross-referenced against statements and authorized expenditures. Unauthorized or unusual activity escalated immediately through a defined reporting protocol.

    Fiscal Manager + Administrative Assistant
  4. 4
    Dual Monthly Financial Reporting

    An executive summary report and a detailed itemized fiscal report delivered to the client representative in their preferred format: digital, print, or secure portal.

    Fiscal Manager → Client Representative
Our Clinical Toolkit

Assessment tools & protocols our GCMs deploy

When you refer to AskVanessa, your patient receives a structured, validated assessment rooted in evidence-based practice, not anecdotal care management. Our clinical team uses the instruments that define the current standard in geriatric care, so you can trust the findings and recommendations that come back to you.

Well-BeingGeriatric Depression Scale (GDS-15) · PROMIS-29 · Philadelphia Geriatric Center Morale Scale
Medication SafetyBeers Criteria · STOPP/START · Morisky Medication Adherence Scale (MMAS-8)
CaregiverZarit Burden Interview (ZBI-22) · Modified Caregiver Strain Index · PHQ-9
TransitionsColeman Care Transitions Model · Four-Pillar Framework · Home Safety Assessment
FunctionADL / IADL Assessment · Comprehensive Geriatric Assessment (CGA)
CommunicationSPIKES Protocol · Advance Care Planning · Goals of Care Conversation Framework
Let's Work Together

Let's build a referral partnership that actually works for your patients.

We respond to every provider referral within 24 hours and send written status updates to your team throughout the engagement, so you always know where things stand with the patients you entrust to us. We serve the Bay Area and Santa Clara County, and we are happy to discuss whether a case is a good fit before you refer.

Download Provider Overview