FOR PROFESSIONAL REFERRAL PARTNERS

For geriatric care managers

This page is for the geriatric care managers and aging life care professionals coordinating private duty home care for older adult clients across cognitive, medical, and family-dynamics complexity. Irina Fain has been operating NJ home care since 2009 and understands the role a professional care manager plays in the client's care system, including the parts that home care agencies often step around.

Audience: geriatric care managers and aging life care professionals

Clinical point of contact: RN Supervisor of record

Referral fee policy: FAINS does not pay referral fees to professional referral partners.

What we deliver for your workflow

Geriatric care managers coordinate care across a client's medical, functional, cognitive, financial, and family-dynamics reality. When the care manager brings in a private duty home care agency, the coordination model matters more than the caregiver credential list.

FAINS is built to work as a member of the care manager's team, not around the care manager. When a care manager is authorized as the point of contact, the RN Supervisor treats that authorization as primary. Plan of care documentation flows to the care manager at initial assessment and at every revision. Monthly billing statements go to the care manager on the standard invoicing cycle. Shift-log summaries flow to the care manager on the cadence the care manager requests (daily, weekly, or event-triggered).

Plan of care changes carry a same-day communication commitment. When the RN Supervisor identifies a change (a shift structure escalation, a caregiver credential tier change, a scope adjustment driven by acuity), the care manager receives the flag before the change reaches the family. That order of communication respects the care manager's role as coordinator and lets the care manager frame the change to the family in the context of the broader care plan.

For the intake conversation itself, the care manager is welcome. When the family or the care manager requests the care manager present at the in-home assessment, the RN Supervisor coordinates the schedule to fit the care manager's availability. Attendance is the care manager's call; the intake process is the same either way.

Monthly progress documentation is the RN Supervisor's standing deliverable to the care manager: a written summary of the client's status, functional trajectory, any acuity changes, any escalation events, and any recommended plan-of-care adjustments the care manager should weigh into the broader care plan.

Cross-disciplinary coordination is built in. When the client's primary care physician requests a clinical update, the RN Supervisor provides it and copies the care manager. When a specialist visit generates orders that affect the home shift (medication changes, therapy prescriptions, DME orders), the RN Supervisor integrates the orders into the plan of care and copies the care manager on the update.

The FAINS methodology in your language

The Fain Standard's seven pillars translated for the geriatric care management workflow:

RN-supervised means a Registered Nurse Supervisor of record on every case, available as the clinical peer-to-peer contact for the care manager. When the care manager needs to talk through a functional decline, a behavioral change, or an acuity question with a nurse, the same RN answers every time. See RN-supervised private duty.

License-verified means the caregiver credential chain-of-custody the care manager can defend to a family or a fiduciary is documented in the caregiver file. NJ Board of Nursing CHHA registry verification before the first shift, with the verification date on file. See License-verified caregivers.

Four-hour minimum shift sets the operational floor. For care managers coordinating cost planning with the family or a fiduciary, that floor is the predictable minimum around which the plan of care builds.

Weekly transparent invoicing produces a defensible monthly billing paper trail the care manager can pull into the client's financial review conversation.

Chemistry-matched caregivers is where the care manager's context becomes operationally decisive. The RN Supervisor uses the care manager's briefing on the family-dynamics reality, cultural context, and household environment to inform caregiver assignment. For dementia and Alzheimer's clients, continuity of a familiar face is a protective clinical intervention; the care manager and the RN Supervisor share responsibility for holding that continuity.

Twenty-four hour cancellation window and private pay only round out the framework. Full detail at the-fain-standard.

How to refer a client

The care-manager-referral pathway:

Call the FAINS line at (908) 460-8886 during business hours (7 AM to 7 PM weekdays), or email fain@fainscare.com with "Care manager referral" in the subject.
Identify yourself as the care manager and confirm your authorized-point-of-contact status with the client or family. Provide the client's name, address, current living situation, cognitive and functional status, the family-dynamics context that will shape the plan of care, and any specific coordination preferences you want built into the case.
The RN Supervisor returns the call within four hours and schedules the in-home assessment at a time that fits the client, the family, and (if you want to attend) your calendar.
Within twenty-four hours of the in-home assessment, the plan of care draft is available to the care manager for review and comment before the shift structure is finalized with the family.
Once the case is live, the standard coordination flow begins: plan of care copies to the care manager at every revision, monthly progress notes on the standard cadence, same-day flag on plan-of-care changes, event-triggered escalation calls.

For live-in, overnight, and 24-hour hourly staffing cases, the shift structure is scoped at assessment and the cost projection reflects the specific structure. For dementia and Alzheimer's clients, the plan of care documents the cognitive picture at intake and the progression the RN Supervisor expects, so the care manager can integrate the acuity trajectory into the broader care plan.

For clients whose case will involve setting transitions (home to assisted living, home to memory care, assisted living to skilled nursing), the care manager typically owns the transition planning and the FAINS RN Supervisor coordinates the receiving-facility handoff on request.

How we work alongside your role

The care manager owns the client's overall care coordination. FAINS owns the private duty home care coverage inside the home. The scope boundary is deliberate and it holds throughout the case.

FAINS delivers caregiver staffing, the RN Supervisor-authored plan of care, shift documentation, monthly billing statements, and the standing coordination flow the care manager has authorized. FAINS does not deliver care management services, does not deliver medical case management, does not deliver family-dynamics counseling, and does not step around the care manager to communicate directly with the family on plan-of-care matters when the care manager is the authorized point of contact.

Handoff points where FAINS coordinates back to the care manager:

Initial assessment: plan of care draft to the care manager for review before finalization.
Monthly: progress note and billing statement to the care manager on the standard cadence.
Plan of care revision: same-day communication to the care manager before the change goes to the family.
Escalation event (fall, ED visit, hospitalization, significant functional decline, behavioral escalation): same-day call to the care manager and to the primary care physician.
Setting transition (home to facility, or facility to different facility): coordination with the care manager on the transition planning and with the receiving facility on the clinical handoff.

Re-verification cadence: the RN Supervisor revisits the plan of care at day thirty, day sixty, and every ninety days thereafter, or immediately when a clinical event triggers the review. Every plan of care revision is documented and available to the care manager on request.

What FAINS does NOT do

FAINS is a private duty home care operator. The scope stays bounded:

FAINS does not pay referral fees to care managers or any professional referral partner. Care managers who refer to FAINS do so because the coordination model respects the care management role.
FAINS does not accept Medicaid or Medicare as a payer for private duty home care. Cases are private pay, long-term care insurance direct pay, or VA Aid and Attendance. For Medicaid-funded Personal Care Assistance the care manager should route to a NJ Medicaid PCA provider.
FAINS does not provide Medicare-reimbursed home health services. For Medicare Part A home health the care manager should route to a Medicare-certified home health agency.
FAINS does not deliver care management services. When a client needs coordinated case management across medical, functional, cognitive, financial, and family-dynamics dimensions, the client needs a care manager; FAINS supplies the caregiver staffing that fits inside the care manager's plan.
FAINS does not accept referrals outside its NJ service area (Union, Somerset, Essex, Middlesex, Morris counties as the current launch geography, with expansion planned).

When any of those situations apply, FAINS says so on the first call. Care managers spend enough of their week on triage; the operationally honest first-call answer saves triage time.

Contact for professional inquiries

For care-manager-referred cases, call the FAINS line and identify yourself as a care manager referral. The RN Supervisor on referral duty returns the call within four hours. Have the client's cognitive and functional status, the family-dynamics context that shapes the care plan, and your authorized-point-of-contact status ready.

Call (908) 460-8886

Email: fain@fainscare.com

Common questions

Will FAINS treat the care manager as the primary point of contact if the family authorizes it?

Yes. When the family or client authorizes the care manager as primary point of contact for care planning, plan of care changes, and monthly billing review, the RN Supervisor treats the care manager as the authorized decision partner. Plan of care copies go to the care manager. Monthly billing statements go to the care manager. Shift notes go to the care manager on the cadence the care manager requests.

Does FAINS share the plan of care and monthly progress notes with the care manager?

Yes. When the care manager is authorized, a copy of the plan of care goes to the care manager at initial assessment and at every revision. The RN Supervisor provides a monthly progress note summarizing the client's status, any acuity changes, any escalation events, and any recommended plan-of-care adjustments. Shift-log summaries are available on request.

How does FAINS handle plan of care changes when the care manager should be looped in?

Same-day flag. When the RN Supervisor identifies a plan-of-care change (shift structure change, credential tier change, escalation to live-in or 24-hour, acuity-driven scope change), the care manager receives a call or secure email the same day. The care manager can weigh in before the change goes to the family.

Will FAINS attend the intake if the family or the care manager requests it?

Yes. When the client, family, or care manager requests the care manager present at the in-home assessment, the RN Supervisor coordinates the schedule with the care manager. Attendance is at the care manager's discretion; the intake process is the same either way.

Does FAINS pay referral fees to care managers?

No. FAINS does not pay referral fees to care managers, geriatric care management practices, aging life care professionals, or any professional referral partner. This is a policy decision made at founding. Care managers who refer to FAINS do so because the coordination model respects the care manager's role.

How does FAINS coordinate with a care manager on complex family-dynamics cases?

The care manager brings the family-dynamics context to the intake and the RN Supervisor writes it into the plan of care. On cases with adult sibling disagreement, guardianship considerations, or capacity questions, the care manager typically holds the authorized-decision-maker channel and the RN Supervisor works through that channel. The caregiver on shift is briefed on communication boundaries at handoff.

What happens when the care manager transitions the client's case to a different setting (assisted living, memory care, skilled nursing)?

FAINS supports the transition. The RN Supervisor supplies the receiving facility with the plan of care, the shift log summary, and any clinical documentation the facility requests. For clients transitioning to assisted living or memory care with a continuing private aide, FAINS can staff a private aide in the facility setting where the facility permits. For skilled nursing transitions, the case typically closes at facility admission and the RN Supervisor supplies the transition documentation.