Case Management and Care Coordination
Have you recently suffered an illness, received a new diagnosis or been hospitalized? When life throws you a curve, sometimes it is helpful to have someone to lean on. Our case managers and care coordinators are here to help you through those challenging times.
What is a Case Manager and Care Coordinator?
Case managers provide a variety of services to help you and/or your family cope with complicated situations in the most effective way possible. This close communication helps you achieve your highest quality of life. These nurses help you identify goals, needs, and resources. Once identified, the case manager, you and your caregiver(s) will work together on a plan to meet these goals. Your nurse will continue to communicate with you or your caregiver to evaluate whether your plan is working and help find resources or connect with services as needed.
Care management and care coordination are two other terms sometimes used to describe this work. Our case managers are Registered Nurses who are also certified in case management (CCM®) by the Commission for Case Manager Certification which is the first nationally accredited organization for case managers. Our care coordinators are specially-trained RN’s and LPN’s who have a passion for patient wellness and independence through communication, education, and advocacy.
Our Case Managers’ and Care Coordinators’ goals are to:
- Ensure a safe transition when you leave the hospital, nursing home or rehab facility.
- Assist in coordinating a 3-5 day post-discharge appointment after discharge from facility.
- Relay any important information in your treatment plans to your physician
- Prevent re-admissions to the hospital, which normally happen within the first 5-7 days of discharge
- Work with you face-to-face in the hospital and office. Phone calls are made to educate and discuss your illness, medication changes, transportation or home safety needs and discharge goals.
- Meet face-to-face with your hospitalists, physicians, or clinicians to determine the appropriate plan of care to help prevent high-risk re-admissions.
- Provide services needed after discharge. Facilitate access to the primary care physician, specialists, ancillary providers, or to make special arrangements such as Home Health Care, Physical Therapy, Occupational Therapy, Speech Therapy, Palliative Care or Hospice.
The philosophy of our nurses is to help our patients achieve the highest level of wellness and independence. By working together with other team members, we are able to meet our patients’ and family’s’ healthcare needs.