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 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 documents.
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, 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.
