Navigating today’s healthcare system is complicated and at times can be overwhelming. As your patient centered medical home we understand the importance of having a central place to access information when coordinating your care, and have individuals who work within your team to be this contact point if and when you need them.
Case Managers are able to follow up with patients at regular intervals, provide self-management support, connection to social services, and care coordination including assistance with appointment scheduling and finding solutions to transportation needs.
Case Managers focus on the Entire patient(social, financial and health) rather than a specific disease. They work with patients to make an individualized care plan and goal setting.
- Health Assessments
- Ongoing clinical assessments
- Hospital pre-discharge planning and post discharge visits
- Self-management education
- Group appointments
- Tracking and documents each patients progress
- Assistance with and referral to local resources such as social services, housing and other life issues