Submitted by Julie Eagan on

Listing of resources is not an endorsement from Advocate Health

--users of information are to validate and to contact their medical team with needs or questions

Stakeholders

Outpatient Case Managers (CMs) [Home; Physician Office]; ER CMs; Inpatient CMs, HaH HH CMs/SNFist-APN; OON UM; Physicians, ACPs, Neuropsychology, Nursing, Chaplaincy; community groups

Social Work and Case Management Corner - Older Adults

Last edit 05/15/2024  For corrections, additions, ideas, please reach out to: thomas.triantafillou@aah.org (welcome to ping at MS-Teams)

Advocate Health Integrated Care Management integrates, coordinates, and simplifies the healthcare experience, impacting the Triple Aim and positioning Advocate to be successful, innovative, and sustainable in the current and future healthcare environments.

  • Improve the patient experience
  • Improve the health of patients we serve
  • Reduce the per capita cost of care

[sharing the AH SW & CM mission, but what follows are separate resources - please do not make a connection, what is shared is a list]

Model

Matters Most, Medications, Mentation-Mood, Mobility, Vision, Hearing, Social or Support Needs, Frailty, Multi-morbidity; risk for abuse; bone health; prognostication, ethics-advance care aspects.

Patient or Next of kin: How can you help a physician?

--State a need (prioritize needs)

--If calling in or using eHealth, include vitals (blood pressure, heart rate, glucose reading if available)

--For medication, requests to include your preferred pharmacy

--Bring a list of needs to hand to the provider, including the one thing you will like to address now

--Share what type of information may assist in completion of cancer screening or immunization (share your barrier on completion of preventive care)

--Complete or continue to update your Power of Attorney of Health (share a copy with the provider; look closely on who is allowed to witness)

 

Patient wants to know more about a health topic

https://medlineplus.gov/

Helpful Numbers for Providers or Patient Stakeholders

Non-emergency Transportation Services Prior Authorization (NETSPAP)/www.netspap.com

Call First Transit at 877-725-0569 (to determine best mode of transportation)

-one needs to use the transportation provider from a list

-once transportation is arranged, call back First Transit do the trip can be approved.

--NETSPAP Standing Prior Authorization Form (04-07-2023)

-M-F excluding federal holidays 8 am to 5 pm (CT)

-Patients: 8777250569

-Providers: 8665039040

TTY 6308731449

Fax: 630-873-1450

PACE-ADA Paratransit (Illinois) 

312-663-4357

Door to Door Service - Give Families Red Pamphlet

https://www.pacebus.com/ada

Ambulance: Covenant Health Ambulance Service, 1619B Weld Road, Elgin, IL 60123

-2248565920/F 2248565806/covenanthealth4@gmail.com

Unable to Pay Electric Bills

Illinois

CEDA/LIHEAP (heating and electricity assistance - need to be income eligible)

-restarts Oct 1 2024

Priority period 1: Oct 1, age 60 or older, household w a person w disability, children 5 or younger, and to be disconnected from one or more utilities

Period 2: Nov 1dt, all eligibel households]

-first come first serve or up to Aug 15th 2025

For intake select Find a Location in the links or contact the Call Center at 800-571-2332

https://www.cedaorg.net/find-services/gas-and-electric/

https://www.cedaorg.net/find-services/

Chicago Hearing Society (Illinois)

773-248-9121

On site sign language interpreting

Sleep Apnea

www.sleep-apnoea-trust.org (UK)

Advocate Palliative-Hospice

630-963-6800

Facx 630-829-1080

Advocate Physicians at Home

Fax: 630-829-1080

Department of Aging Illinois

312-744-4016

Call to set homemaker services, must have SSN#

APS Hotline

866-800-1409

PLOWS Council on Aging (Palos, Lemont, Oak Lawn, Worth)

708361-0219

South Suburban Senior Service (Illinois) [all other Illinois-Chicago Suburbs)

708-596-2222

Physiologist Resources (Staying Toned) - For Older Adults

Under Desk Elliptical Machine Model RB-EB505 

Patient - "I need transportation to see my doctor!"

Paratransit (transportation)

Illinois 312-663-4357

Wisconsin 608-266-4466, or https://www.cityofmadison.com/metro/paratransit (last accessed 12/06/2023)

North Carolina 704-336-2637, or https://www.charlottenc.gov/CATS/Paratransit

South Carolina https://www.greenvillesc.gov/599/Paratransit-Information

Georgia 404-657-7313 (Phone), 404-657-9993 (TTY), or https://ada.georgia.gov/audiences/persons-disabilities

Alabama 205-521-0101, or https://maxtransit.org/paratransit/

Needing Help with Access to Food

https://www.fns.usda.gov/snap/state-directory

"I worry about the summer weather"

Resource for patient education: Staying Safe in Hot Weather | National Institute on Aging (nih.gov)

FMLA (patient - family to ask employer for the preferred form)

https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/WH-380-F.pdf

Link for Patient to Get Immediate Response

Life Alert

Families can contact Medical Alarm Systems 800-921-2160; Phillip Lifeline 800-533-8954; Lifeline 800-806-8522.  

-If patients meet the income criteria for Department of Ageing services through Catholic Charities, Path Light, etc, then the state will provide life alert system.  Otherwise, they can purchase the device. 

Wearable Devices (Consumer Health Informatics)

Can consider a wearable device that can be used to contact emergency services or to assist with a location

Food Pantry - IL (as of 11/13/2023)

Christ Medical Center

Must Register: Patient Demographics (advocatehealth.com) or https://redcapprod.advocatehealth.com/surveys/?s=4DEC8RKDCA7NFK9K

WHERE: 4440 W. 95th Street, Oak Lawn, IL 60453 located on Kilbourn just South of 93rd, Conference Center Circle Drive

WHEN: 2nd and 4th Tuesdays of the Month, 12:00pm until 2:00pm

Trinity Hospital Food Pantry

https://abc7chicago.com/advocate-health-care-trinity-hospital-south-side-free-food/13382692/

Other food pantries - consider using https://www.findhelp.org

--for example, if in Oak Lawn IL, you have https://www.findhelp.org/food/food-pantry--oak-lawn-il

Compassionate Allowances Conditions - Access Medicare Earlier

Patient may quality for Medicare earlier in life  ... due to:

Link: https://www.ssa.gov/compassionateallowances/conditions.htm

Inpatient Clinical Care - Accessing an ACE Report (inpatient nursing, physicians, PT/OT, SW, CM)

Be aware: report that lists aspects of inpatient clinical care aligned with the 5Ms (Matters Most; Medications-Immunizations; Mind (delirium, depression, dementia); Mobility; Multi-morbidity)

Access in Epic your Dashboard

Quality Clarity Report:  ACE Tracker QUA 1000

Quality Clarity Report: ACE Tracker Day Two Snaphot QUA 1065

Psychology Resources - Illinois

a. In- Home Counseling number 888-803-5604, ext. 1003 in- home counseling

-The resource accepts Medicaid, Medicare and most commercial insurances.  Their clinical team consist of LCSWs, LCPCs and Licensed Clinical Psychologists. 

b. https://www.namichicago.org/resources

A Day in Court - Kids are Coming with the Patient or Family

https://www.wicourts.gov/courts/resources/kid/docs/activitybook.pdf
https://www.courts.michigan.gov/courts/supreme-court/learning-center/educational-resources/a-day-in-court-games/

Advocate Aurora Health Memory Services Sharepoint

You will find listed several resources, including instructions to providers or patients or next of kin to tackle several challenges.

Be aware: for Advocate Health Clinical Staff only - may need to request permission on first log in

https://advocatehealth.sharepoint.com/sites/MemoryCareResources (contact: Cristybelle Canda - as of 1/1/2024)

Alzheimer's Association (AA) Illinois Direct Form (Physician to fill), https://www.alz.org/illinois/helping_you/direct_connect_rapid_referral (last accessed 10/02/2023)

For patient-family, AA 24-7 help line (for any patient with a cognitive impairment) 1 (800) 272-3900

How to send a letter to the Alzheimer's Association (AA) through EPIC for them (AA) to reach out to the patient or caregiver (need verbal consent form the patient or substitute decision maker (SDM))

--Open a letter in Epic

--Select "other templates"

--Select Alzheimer's (may get Alzheimer's Knight Foundation) [can make it a favorite]

--In template select if in IL or WI (will provide the correct AA Fax number)

--Complete the form-letter (requires verbal consent to fax to the AA)

--Fax the letter to the AA

Be aware: the AA provides support to any patient with forgetfulness (irrespective of diagnosis - exact cause)

Alzheimer’s Association’s Community Resource Finder (for patient or clinical provider): www.communityresourcefinder.org

Training of Providers for Communicating Diagnosis

Dementia Care and Caregiver Support | Center to Advance Palliative Care (capc.org)

Considerations on discussion on Advance Care Plan, staying healthy, Acute Care, Rehabilitation Care, Palliative Care, Hospice Care

--consider the value to discuss and to enroll a patient in hospice early (i.e., timely enrolment) to allow time for a patient or their support network to fully benefit from services (i.e. spiritual, emotional, clinical, volunteer support)

Patient or Provider Advance Care Plan resource

https://www.nia.nih.gov/health/advance-care-planning

Illinois: https://dph.illinois.gov/topics-services/health-care-regulation/nursing-homes/advance-directives.html

Wisconscin: https://www.dhs.wisconsin.gov/forms/advdirectives/index.htm

When a learning disability is present, history and ongoing monitoring is valuable to distinguish a learning disability progression as compared to a new neurological diagnosis:

https://adscresources.advocatehealth.com/ntg---early-detection-and-screen-for-dementia/

NTG: https://www.the-ntg.org/_files/ugd/c53c74_6b1f8d20f969401b87a6328c679d71c4.pdf

Caregiver Resources
HealthinAging.org
(800) 563-4916 | www.healthinaging.org
Caregiver Action Network
(202) 454-3970 | www.caregiveraction.org
Eldercare Locator
(a national directory of community services)
(800) 677-1116 | www.eldercare.gov
Family Caregiver Alliance
(800) 445-8106 | www.caregiver.org
Medicare Hotline
(800) 633-4227 | www.medicare.gov
National Alliance for Caregiving
(301) 718-8444 | www.caregiving.org

A Place For Mom 866-689-4296 as they have a database and can assess the needs and provide options.

Illinois Department of Human Services

https://www.dhs.state.il.us/page.aspx?item=64594

Caregiver or Patient Resources for Activities to Keep the Mind Healthy

AARP Word Games: https://games.aarp.org/category/word

Alzheimer’s Society of Canada, BrainBooster Activities (including cross words, Sudoku, and word search): https://alzheimer.ca/en/Home/Living-with-dementia/BrainBooster

Mather Telephone Topics: A variety of free classes, groups, and performances via phone - https://www.mather.com/neighborhood-programs/telephone-topics 

SeniorLink Blog: “Helpful Daily Activities for Dementia Patients: 50 Expert Tips and Suggestions to Keep Your Loved One Engaged” - https://www.seniorlink.com/blog/helpful-daily-activities-for-dementia-patients-50-expert-tips-and-suggestions-to-keep-your-loved-one-engaged

Senior Planet: Offers a range of online programs covering technology, fitness, and wellness - https://seniorplanet.org/

TimeSlips Creativity Center: Ideas and prompts for creative engagement at home - https://timeslips.org/resources/creativity-center

Well-Connected: A wide variety of free classes and groups for adults age 60+, available via phone or web - https://covia.org/services/well-connected/ 

Memory Cafes, many of which are meeting virtually now: https://www.memorycafedirectory.com

North Shore Senior Center has been offering daily virtual activities for people with dementia: https://www.nssc.org/daily-virtual-activities-for-people-with-dementia

Care Giver Resources for cases with Dementia

  • Join the Movement! Become a Dementia Friend
    • A Dementia Friend learns about dementia and then turns that understanding into action. We all have a part to play in creating dementia friendly communities! Please click here to learn more.

Chicago - Disability Resource

The HomeMod Program
Mayor's Office for People with Disabilities 
MOPD Field Office
2102 W. Ogden Ave
Chicago, IL 60612

In need of a subacute rehabilitation

https://www.medicare.gov/care-compare/?guidedSearch=InpatientRehabilitation&providerType=InpatientRehabilitation

A move in assisted living is a lengthy process (and it is expensive)

--speak to your physician as early as possible, to allow planning

--you will need a skin test called a PPD

--you will need to ask the location that you have chosen to share with your physician an "intake form" (lists your medical conditions, immunizations, and other aspects) [the facility needs to provide it]

For Illinois - with forgetfullness:

Grace Point Place 630-206-4414 is in Oak Lawn (3/5/2024)

Web search Department of Family and Support Services for Possible Support in Your Area

For Chicago - Caregiver Services Programs

Are you caring for a spouse, parent, relative, or friend?
Caregiver Services Programs from the Department of Family and Support Services may include FREE services such as:
-Education & Training: Learn new skills to care for you and loved ones
-Gap-Filling Funds: Help buying essential items like clothing, furniture, grab bars, eyeglasses, technology, and hearing aids
-One-on-One Counseling: Help with decisions, self-care, and support
-Support Groups: Share your stories, successes, and challenges caring for your loved ones with fellow caregivers

Respite gives you a FREE short-term break
Options include:
- In-Home: Help with activities at home like bathing or cooking
- Facility-Based: Short-term stay at a nursing home

Programs are for individuals of any age who are caring for:
-A Chicago resident age 60+ OR under age 60 with
-Alzheimer’s disease or Related Dementias

Contact the DFSS Senior Services Division Information and Assistance Unit
aging@cityofchicago.org • 312-744-4016

DME damaged during a disaster?

Your durable medical equipment is damaged due to a disaster? https://www.medicare.gov/what-medicare-covers/durable-medical-equipment-replacement-in-disaster-or-emergency (1-800-MEDICARE (1-800-633-4227))

Care under a disaster scenario?

Getting care in a disaster under Medicare? https://www.medicare.gov/what-medicare-covers/getting-care-drugs-in-disasters-or-emergencies

If you have Medicare (please look at current original Medicare source) - on DME

-You may need to buy the equipment.
-You may be able to choose whether to rent or buy the equipment.
-Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims they submit.
-Make sure your doctors and DME suppliers are enrolled in Medicare. It’s also important to ask a supplier if they participate in Medicare before you get DME. If suppliers are participating in Medicare, they must accept assignment (which means, they can charge you only the coinsurance and Part B deductible for the Medicare‑approved amount). If suppliers aren’t participating and don’t accept assignment, there’s no limit on the amount they can charge you

.
What it is DME: It is defined as equipment that meets these criteria:
-Durable (can withstand repeated use)
-Used for a medical reason
-Typically only useful to someone who is sick or injured
-Used in your home
-Expected to last at least 3 years (please check with medicare directly)

Durable medical equipment (DME) coverage
Medicare Part B (Medical Insurance) covers medically necessary DME if your Medicare-enrolled doctor or
other health care provider prescribes it for use in your home.

DME that Medicare covers includes, but isn't limited to:
-Blood sugar meters
-Blood sugar test strips
-Canes
-Commode chairs
-Continuous passive motion machines, devices & accessories
-Continuous Positive Airway Pressure (CPAP) machines
-Crutches
-Home infusion services
-Hospital beds
-Infusion pumps & supplies
-Lancet devices & lancets
-Nebulizers & nebulizer medications
-Oxygen equipment & accessories
-Patient lifts
-Pressure-reducing support surfaces
-Suction pumps
-Traction equipment
-Walkers
-Wheelchairs & scooters


Your costs in Original Medicare (as of 10/2023)
After you meet the Part B Deductible, you pay 20% of the Medicare-Approved Amount (if your supplier accepts assignment). Medicare pays for different kinds of DME in different ways. Depending on the type of equipment:
-You may need to rent the equipment.

To find out how much your test, item, or service will cost, talk to your doctor or health care provider.  The specific amount you’ll owe may depend on several things, like:
-Other insurance you may have
-How much your doctor charges
-If your doctor accepts assignment
-The type of facility
-Where you get your test, item, or service

Provider Ordering DME in Illinois - Home Health

Call 800-564-2025
If you or a loved one is transitioning home from the hospital following surgery, illness or
injury, having the right equipment and resources is important. Not only can home medical equipment make the transition to home safer and easier, it can boost your independence
and quality of life.
Advocate Health at Home does offer a full line of home medical equipment including (payer-insurance-region dependent):
Beds and specialty mattresses; Wheelchairs and cushions; Ambulatory aids; Commodes; Bathing aids; bariatric equipment

Provider Ordering DME - Medicaid

Shield Healthcare

Advance Care Plan

Advance Care Planning & Shared Decision Making in Serious Illness - Home (sharepoint.com), or, https://advocatehealth.sharepoint.com/sites/ModernTeams/ACPSDM?e=1%3A71259f88d9ab42ea995878cd7b32deda

https://advocatehealth.sharepoint.com/:b:/r/sites/ModernTeams/ACPSDM/Shared%20Documents/Epic%20ACP%20Tab/Uploading%20Advance%20Directive%20Documents.pdf?csf=1&web=1&e=iM2RzT

Clinical staff - Link on use of substitute decision button-selection in EPIC: https://advocatehealth.sharepoint.com/:b:/r/sites/ModernTeams/ACPSDM/Shared%20Documents/Epic%20ACP%20Tab/SDM%20-%20Illinois%20Active%20SDM%20Checkbox%20Guide.pdf?csf=1&web=1&e=6sAE6d

Patient - "How to upload Advance Care information through the patient portal": https://advocatehealth.sharepoint.com/:b:/r/sites/ModernTeams/ACPSDM/Shared%20Documents/Epic%20ACP%20Tab/AD%20-%20Uploading%20Advance%20Directive%20Documents.pdf?csf=1&web=1&e=h60Mc9

-patients will not have direct information - a provider would need to download and to share

Declaration for Mental Health Treatment (check with state resources for the latest forms)

Advance Care Planning & Shared Decision Making in Serious Illness - IL Declaration for Mental Health Treatment English.pdf - All Documents (sharepoint.com)

-patients will not have direct information - a provider would need to download and to share

Vynka (Intranet, Top Apps)

-allows remote POLST or POA-H completion

-Vynca: Patient Search (vyncahealth.com), or, https://advocateaurorasearch.vyncahealth.com/searchhttps://advocateaurorasearch.vyncahealth.com/search

Advance Directive for Dementia (dementia-directive.org)

Complete a Power of Attorney or POLST in WI - https://www.dhs.wisconsin.gov/forms/advdirectives/adformspoa.htm

Complete a Power of Attorney of POLST in IL - https://dph.illinois.gov/topics-services/health-care-regulation/nursing-homes/advance-directives.html

Complete a Power of Attorney (Spanish Patients, IL)

https://dph.illinois.gov/content/dam/si/web/idph/files/forms/power-attorney-spanish.pdf

How a patient at Advocate health can use the patient portal (Livewell app) to look at or complete advance directives? Open Advance Care Planning & Shared Decision Making in Serious Illness - Uploading Advance Directive Documents.pdf - All Documents (sharepoint.com), or, https://advocatehealth.sharepoint.com/sites/ModernTeams/ACPSDM/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FModernTeams%2FACPSDM%2FShared%20Documents%2FEpic%20ACP%20Tab%2FUploading%20Advance%20Directive%20Documents%2Epdf&parent=%2Fsites%2FModernTeams%2FACPSDM%2FShared%20Documents%2FEpic%20ACP%20Tab [will work for providers; expect on first log in to be asked to obtain authorization]

Provider, patient, next of kin, searching for Nursing Home (or sub-acute rehabilitation)

If you are considering custodial care (Nursing Home), please look at: https://www.medicare.gov/care-compare/?providerType=NursingHome&redirect=true

On Hearing and Balance

https://vestibular.org/article/coping-support/living-with-a-vestibular-disorder/relaxation-techniques/tai-chi-for-balance/

TaiChi
https://www.greatseniorliving.com/articles/tai-chi-for-seniors
http://www.americantaichi.net/

Poison control 

https://triage.webpoisoncontrol.org/#!/exclusions

Illinois Resources for Older Adults

FindHelp.org (not available at all states Advocate Health services)

Allows you to find free and low-cost resources in your community: • Food • Safe Housing • Childcare • Transportation • Employment • Legal Assistance • And More

Adult Day Service

-Nursing services
Individuals who have Alzheimer’s and other related dementias, developmental or physical disabilities, hypertension, cardiovascular diseases, and other impairments are encouraged to use Adult Day
Services. Licensed nursing staff are available daily to prevent critical events such as falls, ER visits, and hospitalizations. Services provided by on site professionals include:
Health education, such as Matter of Balance, Diabetes Self-Management, and Enhance Fitness Programs, Insulin care and injections, Medication dispensing and health monitoring, Personal lavatory assistance, Physical, occupational and speech therapy services

Contact the Department on Aging
One Natural Resources Way, #100
Springfield, Illinois 62702-1271

www.illinois.gov/aging

Senior Help Line:
1-800-252-8966 (toll-free)
1-888-206-1327 (TTY)


Monday through Friday
8:30 a.m. to 5:00 p.m.
Aging.ilsenior@illinois.gov
Follow @IllinoisDoA

Seniors Helpline (Assist with Homemaker Services) 800-252-8966

Alzheimer's Association 24/7 helpline 800-2723900

2021 Special Needs Cov Transporation IL_Chicago

Department of Aging - City of Chicago Senior Services 312-744-4016 (please look at own area contact number through a web search) (for Chicago aging@cityofchicago.org)

--Home Delivered Meals

--Homemaker service: 80 hours of homemaker services.  Min 4 hours, max 8 hours per session, no nights

--Emergency response system

--Gap funding grant

--Food box program

--Respite (ie care at home; does not apply if a family is paid as a care giver)

Needy Meds (assist with med access) https://www.needymeds.org/

Meals on Wheels (assist with food)

-Chicago/Illinois: 312-744-4016

-Can call 311 to request fresh food delivered

Catholic Charities (Utilities, rent, food, housing etc) 847-376-2100

Life Alert (Medical alert Braclet) 800-517-8196

Lending Closet (assist with medical equipment) https://www.sralab.org/lifecenter/resources/listing-medical-lending-closet-directory (access 10/2/2023)

Senior Companion Program 312-746-8572 or 312-743-0300

--Seniors provide company to other seniors (age 55 or older).  Can have homecare services in addition.

Care Coordination Unit

Case Manager: Needs Based Assessments/Reassessments i.e. Homemaker Service Plan Hours, Home Delivered Meal, Home Monitoring (Life Alert), Adult Day Program etc.

Autonomous Case Management (ACM) Care: 331-645-8195

1111 E 87th Street, Chicago, IL. 60619

https://acmcare.org/case-management-chicago-il/

CEDA's Partner Intake Site Locator 

https://cedaorg.net 

Social Work Resources - IL

2021 Oak Lawn IL SW CM Resources

Mood Disorder Outpatient Programs

Private, stand-alone types of behavioral health treatment facilities:

SunCloud Health: 844-583-0053

Pathlight Mood and Anxiety Center: 866-349-1965

Mental Health and Emotional Support

In-home Counseling

Phone: (888) 903-5604, Option 1

Monday through Friday, 9am-5pm CST

Online Self-Referral: https://www.inhomecounselingservices.com/referral-form/

Fax: (224) 788-5112

Email: info@inhomecounselingservices.com

https://www.inhomecounselingservices.com/

IL Movement

Related to mobility (not PD specific):
“A Matter of Balance” is available throughout Illinois and at several Advocate Aurora sites.  There are also several other Evidence Based Programs.

Below is a link to some of the offerings.

Programs & Classes | Illinois Pathways to Health (ilpathwaystohealth.org)
- Class Search (ilpathwaystohealth.org)

Also, during conferences staff talk about:
-Parkinson Foundation:
Online Courses | Parkinson's Foundation https://www.parkinson.org/resources-support/online-education/courses

-On PD - Look for a Big And Loud Program/ LSVT LOUD

IL Driving and DMV - Physician form to the DMV where the patient is not to drive

Provide update to the DMV on driving, or, "Medical Report For Conditions That May Impair Driving Safely": https://www.ilsos.gov/publications/pdf_publications/dsd_dc163.pdf

Resource for clinitians: https://www.americangeriatrics.org/programs/older-driver-safety

Resource (non advocate) from Warner Law (no disclosure not affiliation with the entity):

https://www.wvpersonalinjury.com/dementia-and-driving/ (accessed 3/5/2024 - not an endorsement)

 

On Housing:

Clarify need (bug infestation, type of location at now vs what needed, etc)

IL Housing

-Patient at or older than 60

--can get assistance from the Illinois Aging - Senior Helpline at 1-800-252-8966

OR, 111 E. Wacker Dr., Suite 1000 Chicago, IL 60601 (866) 454-3571

-Home Seniors

https://homeseniors.org

General: info@homeseniors.org, 773-921-3200

-Will County Center for Community Concerns, https://wcccc.net, 815-722-0722 

-Alliance to End Homelessness in Suburban Cook County, 1-877-426-6515, https://myentrypoint.org 

Homeless Shelter Listing near Oak Lawn

Crisis Center for South Suburbia

Crisis Center for South Suburbia

Worth, IL 2.7 miles outside Oak Lawn, Illinois

To contact the Crisis Center 24 Hour Hotline dial 708-429-SAFE (7233).The Crisis Center for South Suburbia Residential Shelter program offers a safe haven for individual [...]

South Suburban - 2021

--CHF clinic:  708-213-3976

--Cardiac/Pulmonary Rehab: 708-213-3104

Wisconsin Social Services

https://www.dhs.wisconsin.gov/areaadmin/hsd-programs.htm

Wisconsin Acupuncture - AAH (8-9-2022)

Bay Care Clinic Pain & Rehab Medicine – Bay Park/Brown County at 2401 Holmgren Way,Green Bay, WI 54304 920-288-8377

Aurora Fertility Services/Kenosha County at6815 118th Avenue, Kenosha, WI 53209 262-857-5670

Aurora Health Center/Milwaukee County at 3003 West Good Hope Rd., Milwaukee, WI 53209 414-352-3100

Aurora Health Center/Milwaukee County at 6901 W Edgerton Ave, Greenfield, WI 53220 414-421-8400

Aurora Health Center/Milwaukee County at 1575 N Rivercenter Dr, Milwaukee, WI 53212 414-283-8444

Aurora Sinai Medical Center/Milwaukee County at Physical Medicine & Rehab (4th Floor, Easy Street) 945 North 12th Street, Milwaukee, WI 53201 414-219-5241

Aurora Women's Pavilion of Aurora West Allis Medical Center 8901 W. Lincoln Ave, West Allis, WI 53227 414-978-3000

Aurora Wiselives Center 8320 W. Bluemound Road, Suite 125 A, Wauwatosa, WI 53213 414-302-3800

Aurora BayCare Health Center/Outagamie County 1500 Arbor Way, Kaukauna, WI 54130 920-766-3200

Aurora Health Center/Washington County W180N11070 River Ln., Germantown, WI 53022 262-532-8400

Aurora Health Center/Waukesha County 16985 W. Bluemound Rd., Brookfield, WI 53005 262-641-8400

Aurora Health Center/Winnebago County 414 Doctors Court, Oshkosh, WI 54901 920-303-5100

WI Movement

Stepping Class

    Self-Awareness and Self-Care Links - for Clinical Staff

    Take the Professional Quality of Life Scale: https://proqol.org/ProQOl_Test_Manuals.html (5/22/2021)

    Are you looking for an education and training center as a physician on wellness: https://www.commonweal.org, or http://www.practitionerrenewal.ca (5/22/2021)

    In need of mindfullness Medication: Spirit Rock Meditation Center at tttps://spitirrock.org, or www.umassmed.edu/cfm/mindfulness-based-programs/mbsr-cources (5/22/2021)

    Want to explore Poetic medicine: www.poeticmedicine.org (5/22/2021)

    Looking for the Now: civicreflection.org, or join the AAH Narrative Medicine community that meets on a regular basis (5/22/2021)

    Narrative Medicine - Patients or family can join

    For more information or to join our narrative medicine group (First and third Tuesdays from 8 to 9 AM on Zoom), email ACH-NarrativeMedicine@aah.org

    Dr. David Thoele YouTube channel (please subscribe!):

    https://www.youtube.com/channel/UCdKJZ6Vqi_iogTQLVza-c_A

    Topics on the above YouTube channel

    The science behind the 3-Minute Mental Makeover (3MMM): https://www.youtube.com/watch?v=hJNnfb-KIi8&t=5s

    3MMM Walk-through (guided meditation):  https://www.youtube.com/watch?v=HwftA_jmgPY&t=9s

    Alleviating burnout with the 3MMM: https://www.youtube.com/watch?v=wKL-aR0whbY

    A 4th grade teacher describes how she incorporates the 3-Minute Mental Makeover into the classroom during Social Emotional Learning time: https://www.youtube.com/watch?v=H9niA5ddJxs

    A young woman discusses how the 3MMM helped her get her high school degree: https://www.youtube.com/watch?v=R9jCU2-XRNI&t=3s

    Why a trauma surgeon writes with her patients: https://www.youtube.com/watch?v=OYyc2Ge_RY0Dr Dave’s Deep Breathing https://www.youtube.com/watch?v=sup8yrOhPmM

    For more information or to join our narrative medicine group (First and third Tuesdays from 8 to 9 AM on Zoom), email ACH-NarrativeMedicine@aah.org

    OR David at david.thoele@aah.org

    Narrative Medicine Webpage on the Advocate Children’s Hospital website, please feel free to share and use this link when sharing information about the program https://www.advocatechildrenshospital.com/health-resources/support-services/narrative-medicine

    CMA Today, May/June 2021, Volume 54, issue 3. “Talk the talk: Use narrative medicine to enhance patient outcomes,” article by Mark Harris. (Publication by the American Association of Medical Assistants) https://www.aama-ntl.org/cma-today/archives/article?id=8f62e04a-4840-6a90-a81c-ff00003b2c18

    Ask Amy Chicago Tribune 1-24-21 (last letter in this column): https://www.chicagotribune.com/lifestyles/ask-amy/ct-ask-amy-0124-20210124-a32s7ixa3nh6bflmt5bn7ooq54-story.html

    Denver Post: https://www.denverpost.com/2021/01/24/ask-amy-siblings-can-love-but-not-like-each-other/

     Living Lutheran article: https://www.livinglutheran.org/2020/02/im-a-lutheran-david-thoele/

    Study of the 3MMM: https://www.thepermanentejournal.org/issues/2020/winter/7331.html

    Study of the 3MMM Long Term Effects:

    https://www.thepermanentejournal.org/doi/full/10.7812/TPP/20.250

    Better Together: Long-term Behaviors and Perspectives after a Practitioner–Family Writing Intervention in Clinical Practice (thepermanentejournal.org)

    This is the permanent page for donations: Narrative Medicine - Advocate Charitable Foundation (aahgiving.org): https://secure.aahgiving.org/site/Donation2?5384.donation=form1&df_id=5384&mfc_pref=T

    Narratives about 3MMM

    Here is a story about one of my patients. It’s up and posted on our blog: https://advocategiving.org/2022/02/15/how-narrative-medicine-helps-nurture-the-mind-and-body/

    Narrative medicine completely changed my life for the better. Interview with patient Haley Schwartz. Advocate Health Care Charitable Foundation Blog Summer 2020 (not available as of 5-23).

    https://advocategiving.org/2020/06/29/narrative-medicine-completely-changed-my-life-for-the-better/

    Facebook Group: The Weekly Breather: Telling our Stories

    Facebook Page: INMI, The International Narrative Medicine Institute

    Patient/Physician Narratives:

    Thoele DG: How I chose my specialty. Physicians Practice. August 29, 2011. https://www.physicianspractice.com/view/how-i-chose-my-specialty

    Harris J and Thoele DG: Struggles, Gratitude and Love. Hektoen International. Vol. 3, issue 3, Fall 2011. https://hekint.org/2017/03/09/struggles-gratitude-and-love/

    Thoele DG: No good options. Hektoen International. Vol. 4, issue 4, Fall 2012. https://hekint.org/2017/01/23/no-good-options/

    Thoele DG: The Arm.  Pulse: Voices from the Heart of Medicine. June 2014. https://pulsevoices.org/index.php/pulse-stories/380-the-arm

    Thoele DG:  The Perfect Day.  Ars Medica. August 2015. https://ars-medica.ca/index.php/journal/article/view/8

    Thoele DG: The Boy with Two Dads. Hektoen International. Vol. 8, issue 2, Spring 2016. https://hekint.org/2017/01/29/the-boy-with-two-dads/

    Thoele DG: Saying Goodbye through the Loving Hands of a Nurse. David Thoele. Pulse: More Voices. 05 April 2020

    https://pulsevoices.org/index.php/pulse-more-voices/more-voices-2020/covid-19/2478-saying-goodbye-through-the-loving-hands-of-a-nurse%E2%80%9D

    Chicago Sun Times, March 2, 2021, Op Ed. ‘I hate masks, too,’ I told my teenage patient and his mother, ‘but I like living life’: https://www.google.com/amp/s/chicago.suntimes.com/platform/amp/2021/3/1/22307744/covid-19-face-masks-social-distancing-pediatrician

    Resources - SW

    2021 Enterprise Population Health Ambulatory Care Management Program Deck

    2021 BCBSIL HMO Glucose Meter

    2021 CCM Direct SNF Admission Process

    2021 Cigna ESRD Meal Benefit Summary (9/14/2020)

    2021 Humana Medicare Advantage Preferred DM Supplies

    2021 Humana Over the Counter Catalog

    2021 Payor CM Contact List

    2021 You have Been Referred aPlaceforMom

    Cognitive Assessment & Care Plan Services - CPT 99483 [last edit 1-30-2022]

    If your patient shows signs of cognitive impairment during a routine visit, Medicare covers a separate visit to more thoroughly assess your patient’s cognitive function and develop a care plan – use CPT code 99483 to bill for this service. 

    What’s Included in a Cognitive Assessment? 
    The cognitive assessment includes a detailed history and patient exam. There must be an independent historian for assessments and corresponding care plans provided under CPT code 99483. An independent historian can be a parent, spouse, guardian, or other individual who provides patient history when a patient isn’t able to provide complete or reliable medical history. 

    Typically, you would spend 50 minutes face-to-face with the patient and independent historian to perform the following elements during the cognitive assessment: 

    • Examine the patient with a focus on observing cognition 
    • Record and review the patient’s history, reports, and records 
    • Conduct a functional assessment of Basic and Instrumental Activities of Daily Living, including decision-making capacity
    • Use standardized instruments for staging of dementia like the Functional Assessment Staging Test (FAST) and Clinical Dementia Rating (CDR)
    • Reconcile and review for high-risk medications, if applicable 
    • Use standardized screening instruments to evaluate for neuropsychiatric and behavioral symptoms, including depression and anxiety
    • Conduct a safety evaluation for home and motor vehicle operation 
    • Identify social supports including how much caregivers know and are willing to provide care
    • Address Advance Care Planning and any palliative care needs 

    TCM Services Requirements [last edit 1-30-2022]

     

    The 30-day TCM period begins on a patient’s inpatient discharge date and continues for the next 29 days ("inpatient"; "SNF"; not ED, not urgent care). ​

    TCM services begin the day of discharge from 1 of these inpatient or partial hospitalization settings:

    • Inpatient Acute Care Hospital
    • Inpatient Psychiatric Hospital
    • Long-Term Care Hospital
    • Skilled Nursing Facility
    • Inpatient Rehabilitation Facility
    • Hospital outpatient observation or partial hospitalization
    • Partial hospitalization at a Community Mental Health Center ​

    After inpatient discharge, the patient must return to their community setting. ​

    These could include:

    • Home
    • Domiciliary
    • Nursing home
    • Assisted living facility​

    99495 (visit in 14 days)/99496 (visit in 7 days):

    • Communication (direct contact, telephone, electronic) with the patient and /or caregiver within 2 business days of discharge
    • Medical decision making of at least moderate complexity during the service period
    • Face-to-face visit, within 14 or 7 calendar days of discharge (depends on visit and timing from discharge)

    Reference https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

    Pharmacy - Medications Too Expensive

    Trelegy fax to 855-474-3063 GSK (patient assistance program)
     
    Apixiban fax to 800-736-1611 Bristol Myers Squibb (patient assistance program)

    Palliative

    Palliative Care Contact

    Contact Palliative Coordinator at 833-268-1268 or 630-571-8990 (Illinois)

    Symptom Management Resource

    Palliative Care and the Management of Common Distressing Symptoms in Advanced Cancer: Pain, Breathlessness, Nausea and Vomiting, and Fatigue | Journal of Clinical Oncology (ascopubs.org)

    https://ascopubs.org/doi/10.1200/JCO.19.00470