About Our Program
Since 2008 our clinical team comprised of registered nurses, social workers and care coordinators with the support of our medical directors has provided both in-home and telephonic support, care coordination and early identification of problems for individuals who reside in the community and are served by our program. We work with the individual’s personal physician and other healthcare providers to achieve smooth transitions between healthcare settings, help coordinate the delivery of care and support in the community so that individuals are able to remain in their own home while reducing unnecessary hospitalizations and emergency room visits.
Our Community Based Care Management Program provides:
- An initial telephonic or in home assessment by a registered nurse to review medical status, medication management, safety, fall risk, and any other concerns that may impact the individual’s health.
- Based on the initial assessment, additional in-home or telephonic visits may be scheduled.
- If indicated, a social worker will be part of the care management team to make referrals for community-based support programs and resources.
- Support and education for treatment options and medications, as well as transparency around changes in condition for the individual and those who care for them.