Core Services Overview

Core Services

Non-clinical care coordination, transitional support, navigation, and advocacy services

ElderPath provides structured support to help older adults, medically complex individuals, and their families navigate care needs and transitions across healthcare and community settings. Our services focus on coordination, communication, and continuity—not placement, referrals, or clinical care.

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Care Coordination Services

Care coordination involves organizing, aligning, and supporting services across multiple providers and systems to promote health, safety, and continuity of care.

ElderPath provides non-clinical care coordination to help individuals and families understand care plans, connect services, and reduce gaps during periods of change or complexity.

Care Coordination Services Include:

  • Comprehensive review of medical, functional, and social needs
  • Organization of care-related information and documentation
  • Identification of care gaps, risks, and transition needs
  • Coordination with healthcare providers, social workers, and care teams
  • Support understanding treatment plans, recommendations, and next steps
  • Ongoing communication with families and authorized representatives
  • Follow-up support to ensure services remain aligned

Important: Care coordination services are non-clinical and do not replace medical care, case management by managed care plans, or licensed provider services.

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Transitional Support Services

Transitional support focuses on helping individuals safely and smoothly move between care settings while maintaining continuity and reducing risk.

ElderPath supports individuals and families before, during, and after transitions to ensure services are coordinated and expectations are clear.

Common Transitions Supported:

Hospital to skilled nursing facility
Skilled nursing facility to community
Home to assisted living or board & care
Community to higher levels of care when needs change

Transitional Support Services Include:

  • Transition readiness assessment and planning
  • Coordination of services prior to discharge or move
  • Support understanding discharge instructions and care plans
  • Communication with receiving providers and care teams
  • Post-transition follow-up to promote stability and continuity
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Assisted Living & Community-Based Transition Support

ElderPath provides coordination and transition support for individuals and families considering or preparing for community-based residential care settings, such as assisted living or board & care homes.

Our role is to support understanding, coordination, and planning—not placement or referrals.

Services Include:

  • Clarifying care needs versus housing needs
  • Education on levels of care and service models
  • Coordination of assessments required by providers or programs
  • Support organizing tours or conversations with licensed providers
  • Assistance preparing for transitions and service implementation
  • Ongoing coordination after transition, when requested

Important: ElderPath does not act as a placement agency and does not make housing or care decisions.

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Memory Care & Cognitive Transition Support

Transitions involving Alzheimer's disease or other cognitive conditions require additional coordination and communication.

ElderPath supports individuals and families navigating memory-related care needs by coordinating services and supporting continuity during transitions.

Services Include:

  • Coordination with memory care providers and care teams
  • Family education and expectation-setting
  • Support aligning care plans with cognitive and safety needs
  • Assistance during behavior-driven or safety-driven transitions
  • Follow-up support after transitions to monitor adjustment
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Publicly Funded Care Navigation & Coordination

ElderPath assists individuals and families in understanding and navigating publicly funded care systems, including Medi-Cal-related programs and community-based services.

We provide education, coordination, and transition support while working alongside licensed and plan-approved providers.

Programs We Help Clients Understand:

Medi-Cal
CalAIM initiatives
Enhanced Care Management (ECM)
Community Supports
Assisted Living Waiver (ALW)

Public Benefits Support Includes:

  • Education on how programs work and what they cover
  • Coordination with plan-approved and licensed providers
  • Support gathering information and documentation
  • Alignment of transition planning with available benefits
  • Ongoing coordination alongside care teams

Important: ElderPath does not provide Medi-Cal benefits directly, does not determine eligibility, and does not bill Medi-Cal.

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Family & Caregiver Support

Care transitions impact families and caregivers as much as individuals.

ElderPath provides guidance and communication support to help families understand care options, roles, and next steps.

Support Includes:

  • Education on care processes and expectations
  • Communication facilitation between families and providers
  • Support during difficult or time-sensitive decisions
  • Ongoing guidance throughout transitions

Important Service Clarifications

Understanding our role and responsibilities

We Are NOT:

  • A placement agency or referral broker
  • Providers of medical, clinical, or legal services
  • Determiners of eligibility for public benefit programs

We ARE:

  • Non-clinical care coordinators and navigators
  • Transitional support specialists
  • Education and advocacy providers

Decision-Making Authority

All care and housing decisions remain with the individual, family, and licensed providers. ElderPath's role is to support coordination, communication, and continuity—not to make decisions on behalf of clients.

Services are non-clinical unless otherwise specified by contract.

Questions About Our Services?

Contact us to discuss how ElderPath can support you or your loved one through care transitions and coordination needs.