Chronic Care Management is coordinated care to help clients stay on track by getting support from home visit doctors and nurses between their routine office visits. Clients with multiple chronic conditions can have a significant risk of death, hospital admission, or functional decline. Our care manager evaluates clients for monthly care management and after-hour access to support health care goals.
Transitional Care Management is timely home-based clinical assessment made after a hospital discharge. This is a vulnerable period between the inpatient and community settings. Oversight and coordination of care between specialist, diagnostic center, pharmacy, and other services are completed by the Transitional care manager.
Geriatric Care Management is a palliative model of care with specialized interdisciplinary care for clients. The focus is on symptoms and stress associated with the illness. This care includes caregiver support and advanced care planning. Our expert palliative care team is directed by the client’s health care wishes. Need to plan for Geriatric Care? Read our Guide.