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
Assist with access to medical care, including home and community services
and medical equipment.
- Develop a 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
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 the hospital team, primary care physician,
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