Continuum (Long Term Care)
Coordinated long term care
Follow mobility, cognition, breathing and everyday function over time, coordinate nursing and medical oversight, and keep the family informed, at home or in a care home.
An annual assessment weighted to function and comfort, regular nursing and physician oversight, and someone steering when care becomes several things at once, so that long term care stays one plan.
Fees are tailored to you. Call us on (250) 818-4425 for a written quote; every included service is itemized in writing before you begin.
Suggested according to your frailty level and needs.People whose frailty level means they need ongoing daily support, at home or in a long term care setting, and the families who help them. The difficulty is rarely one condition, it is several of them and nobody holding the thread, so the emphasis is on comfort, function and coordination.
How this one differs
A pathway, not only a membership
Continuum is a coordinated long term care pathway for people living with frailty or several conditions at once. It brings clinical care, nursing and coordination into one arrangement, and it is entered at the point where care is becoming complicated, not at a particular birthday.
This page is written for the family member who is arranging care. If you are arranging it for yourself, everything here applies in the same way.
Membership fees
Let's find the right fit, then put a number on it.
Call us and we will talk it through and give you a clear written quote, with no obligation. You will also receive a written record of exactly what your membership includes before any services begin.
How your level is decided
Everyone starts with a yearly assessment. The team reads the results together with your frailty level and recommends the level of care that fits. The choice is yours: you can take a lower level, and we will tell you plainly if it is below what we recommend, now and as things change.
What this membership includes
An annual health and function assessment
The usual medical review, plus direct measurement of strength, balance, walking speed, breathing and memory, the things comfort and independence depend on.
Functional review twice a year, or whenever things change
Because function can change faster than bloodwork, it is measured more often than once a year - and again on any change in condition, not only by the calendar.
Falls and mobility planning
Practical work on balance, strength and the home environment, before a fall rather than after one.
Support when something changes
A care team that knows your history and can help you understand what needs attention and coordinate the appropriate next steps. Coordination does not provide priority or preferential access to publicly insured services.
Medication review
A regular look at everything you take together, which is often where the easiest gains are. Pharmacogenetic testing is available as an option.
A named care coordinator, when care becomes complicated
One person who knows the situation and helps hold the moving parts together, with your consent - specialists, allied health and home support kept in step with the plan. Coordination does not provide priority or preferential access to publicly insured services.
Care wherever you live
Where appropriate, Monarch may provide or coordinate uninsured healthspan services at home or in a care home. Any MSP-insured physician services provided by an independent physician are separate from Monarch Health and are not included in the membership.
Support for the family
Clear communication, planning conversations, and someone on the care team who can answer a question - with the member's consent.
What we measure, and how often
An annual assessment with a functional review every six months, weighted toward independence - and reassessed whenever the situation changes.
Annual full assessment; functional review every six months, and again whenever there is a meaningful change in condition.
What the assessment covers
- Medical and medication history, reviewed together as a whole
- Laboratory assessment and vitals
- Strength, balance, gait speed and mobility
- Memory, thinking and mood
- Mood, purpose and social connection
- Day-to-day function at home, and what help is needed
- Home safety and the home environment
- What matters most to the person, and to the family
How change is noticed, and what happens next
How change is identified
Strength, balance, walking speed and memory are measured at your annual assessment and at a functional review every six months, and again whenever there is a meaningful change in condition.
When a concern arises
Your care team reviews what has changed and, with your consent, involves your family physician and others in your care so the next steps are coordinated. Coordination does not provide priority or preferential access to publicly insured services.
How the membership works between assessments
An assessment once or twice a year is not a relationship. These are the things that keep Monarch present in between.
A plan built around what you want to keep doing
Goals are set in terms of activities and independence, not abstractions.
A named point of contact
A care team member who knows your plan, and a single coordinator, not a directory, when care is complicated.
Family kept in the loop, with your permission
Where you want family involved, they can be - on your terms and with your consent, working from the same plan as the clinical team.
A written summary after every review
Something you can keep, read later, and share with whoever you choose.
Clinical programs this membership draws on
Programs are delivered within a membership rather than bought separately. Which ones apply depends on what your assessment finds and what you and your physician decide to work on.
How this works with the public system
Publicly insured services remain publicly insured. Where an independently practising physician provides an MSP-insured service, that service is separate from Monarch Health and is billed through MSP in accordance with applicable requirements. Membership fees do not cover or provide priority access to MSP-insured services. This membership covers uninsured services - assessment, prevention planning, functional review, care coordination, monitoring and family support. It does not replace your family physician or publicly funded home and community care, and it does not provide faster access to MSP-covered tests or specialist referrals.
