Care Management Services:

  • Comprehensive Assessment

A respectful yet comprehensive assessment of the client’s medical, social and environmental condition enables the RN Care Manager to have an evidence base of information to identify strengths, resources and areas for improvement.  A profile is developed on which resources are listed and recommendations are made. Short-term as well as long-term goals are addressed as part of the assessment.

  • Individualized, Client-Focused Plan of Care

The RN Care Manager develops an individualized plan of care based on the assessment of the client’s needs. The Plan utilizes the available support the client has in place and builds additional support as needs arise.

  • Emergency Planning

Prepare emergency information to assist with important information for medical personnel such as medication lists, insurance information, advanced directives and contact information on prescribing physician, attending physician, and healthcare surrogate.

  • Hurricane Evacuation Preparation and Coordination

Develop a hurricane evacuation plan, locally or to a designated out-of-area destination, and activate the plan when necessary.

  • Attend Physician Visits

The RN Care Manager (with client authorization) can escort and attend physician visits with the client to review medication efficacy, help reinforce physician instructions, and discuss test results.

  • Medication Management

Load prescribed medications in daily dispensers (medication dose planners) for home use by the client. Monitor medication compliance, efficacy and side effects.

  • Coordination and Management of Care

Authorized services are coordinated around the clients established support systems.  Any services that need to be implemented are initiated, supervised, monitored and adjusted based on need and client satisfaction.

  • Arrange Personal Services and Transportation

Transportation is arranged with commercial or medical transport agencies, or the RN Care Manager can escort the client to appointments whenever necessary.

  • Travel Availability

The RN Care Manager is available for travel when necessary. Assisted travel and air ambulance service can be arranged interstate or internationally.

  • Continuous Monitoring of Service Delivery and Client Needs

All services are monitored on an ongoing basis via follow up telephone calls and client visits. When communication with family or support providers is requested the RN Care Manager will correspond with each person authorized by the client or guardian.

 

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