Care Management and Transition of Care Team

Care management

Care Management — Our Care Management team includes a Registered Nurse, care coordinators, and medical social workers who provide a more comprehensive level of care and assist our patients to navigate the increasingly complex healthcare system.

Goals of Care Management:

  • Assist in communication between you, your primary care physician, and your specialists.
  • Assist with access to medical care, including home and community services and medical equipment.
  • Develop personalized care plan for each patient
  • Chronic Disease Management (for example, COPD, heart failure, diabetes)
  • Coordinate care after hospitalization
  • Support in making healthcare decisions including goals of care and Advance Care Planning to complete Living Will and Healthcare power of attorney documents.

Our Transitions of Care — Our team is notified immediately if you are hospitalized and will reach out to you and your caregivers to help coordinate a smooth transition for discharge.

  • Assist in communication between hospital team, primary care physician and caregivers.
  • Assist with community resources like home health and medical equipment
  • Review your medications
  • Help you and your care team stay connected including scheduling follow up appointments.