Care Management Services — Stand-Alone

Process:

1. Referral and telephone screening. Referrals can be made in-person, via the telephone or internet and may come from any source. Once a referral is made, then a brief telephone screening is completed and if both parties agree to move forward, a request is made to the care manager to perform an initial assessment. Once this request is made, the care manager will contact the referral source within 4 hours to schedule an initial assessment.
2. Initial Assessment. An in-person visit by the Care Manager is conducted at which time pertinent records and information are reviewed. The client's spouse, family and/or significant others are interviewed and the client’s specific goals and objectives and their measurement are defined.
3. Care Plan. A Care Plan is developed by the Care Manager in collaboration with the client and his or her spouse, family or significant other and is based on the initial evaluation information. Once the Plan has been formulated, it is reviewed by the Medical Director and Executive Director for their input. The final version of the Plan is then presented to the Client or his/her designee for final approval. Once the Plan has been approved, then a service agreement is signed. Fees for the Care Plan are billed to the client every 2 weeks.
4. Care Plan Implementation. Goals are reviewed regularly between the client, family and Care Manager to determine if they are on target or whether changes need to be made. The Care Plan is completed once the goals are achieved or it is mutually determined that goals are not achievable and a mutual decision is made to terminate the Care Plan.

Examples of how Care Management can help:

• Healthcare Navigation – Care Managers can assist individuals and/or families with a new or existing diagnosis such as cancer, MS, ALS or others to be educated, confident, and thorough in their treatment decisions as well as enable them to manage their health and lives so both short term and long term to reach their optimum level of wellness. From direction to educational resources, providing knowledge to evaluate treatment centers, understanding the roles of specialists, and diagnostic tests, to benefit management, Care Management can provide the resources to help individuals move through the healthcare system efficiently.
• Disability Management – Care Managers can assist individuals and families to manage a disability throughout a lifetime. This may include training of caregivers, accompanying the individual to MD appointments, periodic reassessments to determine the need for skilled therapy services when a significant improvement or decline occurs, etc.
• Support when families live far away – Care Managers can fill the role of a family member that lives far away. They can be involved to whatever level the family needs from managing caregivers and household expenses to managing healthcare needs by attending physician appointments, advocating for medication changes, etc.

We also offer complete Care Management services:
Read More