Care Management and Transition of Care Team
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.
