Care Management

Health care beyond your doctor’s office

Care Management includes several programs that strive to improve care for patients with complex medical issues. We work primarily with medically vulnerable patients – patients with complex or chronic diseases, older adults, and those who have trouble leaving home for their care.

The Care Management team works closely with your primary care physician (PCP) to coordinate your health care at home or during your transition from a hospital stay. Our goal is to improve health outcomes and peace of mind, working in partnership with patients to develop a care plan based on individual needs, treatment options and values.

• RN Care Managers work with patients with chronic disease to provide education and resources to improve health outcomes. They also check in with patients following a hospital stay and help coordinate follow-up care with the PCP.
• The Clinical Home Team provides care to patients in their home when they are not able to access care in the clinic setting. ARNPs address acute and complex medical issues and help develop a care plan that aligns with the patient’s goals and values.

Care Managment services may include:

• Medication management
• Nutrition education and diet planning for weight management
• Diabetes care and monitoring
• Congestive heart failure support
• Chronic disease management
• Pain management
• Palliative and therapeutic options
• Advance directives and care planning
• Help navigating the healthcare system
• Referrals to financial and other resources