Care coordination dashboard

Rosalind M. (demo) · Bergen County, NJ · Age 78

Demonstration data. This case, its contacts and its records are fictional and exist only to show how the Navigator works.

Safety alerts

Wandering after dark
critical
Two episodes in the last 30 days of leaving the house unaccompanied in the evening. Front door has no alarm.

If she leaves and cannot be found, call 911 immediately. Add door chimes tonight and register with the local police department's vulnerable-resident program.

Unsupervised cooking
high
Burner left on twice in two weeks.

Install a stove shut-off device or remove the stove knobs. Ask the OT during the home health evaluation.

No overnight supervision Tue/Thu
high
Spouse works overnight shifts twice weekly. No coverage is arranged.

Raise this as the top care gap during the ADRC assessment and the GUIDE intake.

Caregiver strain
moderate
Daughter reports 32 unpaid hours weekly and disrupted sleep.

Request Statewide Respite screening and caregiver counseling through the county aging office.

If someone is in immediate danger or wandering right now, call 911. For suspected abuse, neglect, self-neglect or exploitation, contact county Adult Protective Services at 1-800-792-8820. This app cannot dispatch help.

Today's priority actions
Ordered by urgency, value and dependency.

Close the evening wandering risk tonight

Contacted

Two unaccompanied evening exits in 30 days is a life-safety risk that outranks every benefit application on this plan.

Owner: Marcus (backup caregiver) · Due: 2026-08-07

Build the benefits file

Pending documents

Almost every delay in benefits work is a missing document. Collecting them once removes the delay from every later application.

Owner: Daniela (coordinator) · Due: 2026-08-09

Locate the 2004 long-term-care policy and the spouse's DD-214

Contacted

A long-term-care policy commonly pays on cognitive impairment alone, and veteran pathways cannot be screened without service records. Both are frequently forgotten.

Owner: Marcus (backup caregiver) · Due: 2026-08-15

Request a Medicare home health evaluation from the primary care physician

Contacted

A home health evaluation brings a nurse and an occupational therapist into the house, produces safety recommendations, and does not depend on income or assets.

Owner: Daniela (coordinator) · Due: 2026-08-10

Open the full 30-day plan
Upcoming appointments & deadlines

County comprehensive in-home assessment

2026-08-13 · Bergen County Division of Senior Services

Patient home · Owner: Marcus (backup caregiver)

GUIDE organization intake call

2026-08-11 · Participating GUIDE provider (to be confirmed)

Phone · Owner: Daniela (coordinator)

Neurology follow-up

2026-08-18 · Dr. S. Patel

Valley Health System · Owner: Daniela (coordinator)

Elder-law consultation

2026-08-28 · NJ elder-law attorney (to be booked)

Phone · Owner: Elder-law consult

Weekly care hours
Required vs. funded, privately paid, unpaid family and uncovered hours. Latest week: 16 hrs uncovered and 48 hrs carried by family.

Hours are family-reported estimates, not a clinical determination of need.

Benefits pipeline
21 programs tracked.

Medicare Cognitive Assessment & Care Planning Visit

Applied
No income or asset test

Next: Collect the written care plan from Dr. Rivera's office · Daniela (coordinator) · due 2026-08-14

Medicare GUIDE Model (Dementia Care Navigation)

Assessment required
No income or asset test

Next: Call two participating organizations to confirm alignment eligibility · Daniela (coordinator) · due 2026-08-11

Medicare Home Health Benefit

Eligible to apply
No income or asset test

Next: Ask Dr. Rivera to order a home health evaluation · Daniela (coordinator) · due 2026-08-10

NJ Aging & Disability Resource Connection (ADRC)

Applied
No means test - needs assessment applies

Next: Confirm the in-home assessment date in writing · Marcus (backup caregiver) · due 2026-08-13

Home-Delivered and Congregate Meals

Awaiting documents
No means test - needs assessment applies

Next: Send the dietary restriction list to the county nutrition program · Marcus (backup caregiver) · due 2026-08-12

County Senior Transportation and Escorted Transportation

Needs verification
No means test - needs assessment applies

Next: Confirm whether an escort is required for a rider with dementia · Marcus (backup caregiver) · due 2026-08-18

Open the full pipeline
Services currently active

Caregiver Education, Counseling and Support Services

Counseling, training, support group

Social Security Retirement, Spousal and Survivor Benefits

Monthly income already in payment

Medicare Durable Medical Equipment

Bathroom safety equipment

Documents needed
Written dementia care plan
requested
Current medication list
expiring
Durable power of attorney
missing
Long-term-care policy (2004)
requested
Spouse DD-214
missing
Open the document vault
Caregiver schedule
Gaps are the hours no one is covering.

Monday

Daughter 8a-12p; spouse 12p-overnight

Tuesday

Daughter 8a-4p; spouse works overnight

Gap: No overnight supervision 11p-7a

Wednesday

Private aide 9a-1p; spouse rest of day

Thursday

Daughter 8a-4p; spouse works overnight

Gap: No overnight supervision 11p-7a

Friday

Private aide 9a-1p; spouse rest of day

Saturday

Spouse all day

Gap: No caregiver relief

Sunday

Spouse all day; daughter 4p-8p

Gap: No caregiver relief

Calls & contact history

NJ ADRC

Assessment scheduled

2026-08-01 · phone · Daniela

Described diagnosis, ADL needs and the overnight supervision gap. Requested a comprehensive in-home assessment and asked for written confirmation.

Dr. Rivera (primary care)

Contacted

2026-07-29 · phone · Daniela

Requested a home health evaluation order. Office said it would route to the physician for signature.

DME supplier

Approved

2026-07-26 · portal · Daniela

Shower transfer bench approved under the Medicare DME benefit. Delivery pending.

Medicare

Contacted

2026-07-22 · phone · Marcus

Confirmed Medicare home health is intermittent and skilled. Representative stated Medicare does not cover ongoing custodial or 24-hour home care.

Open contacts & call log
Denials & appeals

No denials recorded. If one arrives, upload the written decision letter the same day - appeal deadlines run from the date on the notice.

Verification alerts
Rules flagged for human review before they are relied on.

Medicare Caregiver Training Services

Last verified 2026-06-28 · needs verification

County Senior Transportation and Escorted Transportation

Last verified 2026-06-20 · needs verification

Adult Day Services

Last verified 2026-06-15 · needs verification

Telephone Reassurance and Wellness Check Programs

Last verified 2026-06-15 · needs verification

Employer, Union, Pension, Railroad and Public-Employee Benefits

Last verified 2026-06-15 · needs verification

Long-Term-Care and Life Insurance Benefits

Last verified 2026-06-15 · needs verification

Jersey Assistance for Community Caregiving (JACC)

Last verified 2026-07-02 · needs verification

Statewide Respite Care Program

Last verified 2026-07-02 · needs verification

Alzheimer's Adult Day Services Program

Last verified 2026-06-15 · needs verification

MLTSS and PACE

Last verified 2026-07-02 · needs verification

Bergen County resources
New Jersey delivers most aging services through its 21 county offices. Confirm your county's direct number against the official state directory before calling.

Statewide ADRC

1-877-222-3737

nj.gov ADRC

County aging office directory

Official list of all 21 county offices

nj.gov county directory

Adult Protective Services

1-800-792-8820

nj.gov APS

Owning a home or a vehicle never removes the programs above that have no income or asset test. Financially restricted programs still require a formal screening - and asset-planning questions belong with a qualified New Jersey elder-law attorney, not with this app.