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.
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.