Care Management is essential to everything we do. P4CC Care Managers ensure the full circle continuity of care that occurs between providers, hospital, and home:
- Helping patients and practices manage chronic diseases according to national evidence-based treatment guidelines
- Targeting care management services to help patients avoid unnecessary emergency room visits, hospitalizations, and readmissions
- Assisting patients with hospital transition to ensure medications, services, and equipment are in place and properly utilized
- Conducting medication reconciliation to ensure prescriptions are filled and no discrepancies exist
- Linking the patient back to the medical home after a hospital discharge
- Coordinating care with the medical home and other community agencies providing supportive services
Roles of the Care Management Team:
- Primary Care Manager (RN/BSW): As the lead on the care management team, they are responsible for initial engagement with the patient, face to face encounters, home visits, assessments, establishing patient centered goals and care plan implementation.
- Care Coordinator (Non-licensed): Responsible for completing social, behavioral, and emotional at-risk assessment through phone calls, clinic visits, and occasional home visits when warranted. Link patients to community resources, Support the RN and SW Care Manager in the holistic multi-disciplinary team approach.
- Clinical Care Coordinator (LPN): The role of the Clinical Care Coordinator is to provide support to the RN Care Manager in the holistic multi-disciplinary team approach, which includes social and emotional assessment, planning, facilitating education and advocacy for the patient protocol.
- Other Disciplines will remain valued members of the team as well.