Assessment and Care Planning
Our CCM team will conduct a thorough evaluation of the patient’s needs to craft a personalized care plan. This process involves pinpointing any care deficiencies, orchestrating collaboration among various healthcare providers, and offering educational and supportive resources to both patients and their loved ones.
Medication Reconciliation, Optimization and Education
One of the cornerstones of our CCM approach is the meticulous management of medications during care transitions. This entails reconciling current medication lists, resolving any inconsistencies, deprescribing if needed and providing detailed guidance to patients and their caregivers on correct medication usage, dosages, and awareness of possible side effects. Our goal is to ensure patients and caregivers have a comprehensive understanding of medication protocols to reduce errors and enhance safety.
Coordination of Care and Effective Communication
Our CCM prioritizes the essential roles of communication and coordination across the healthcare spectrum. We facilitate the exchange of crucial medical information, including test outcomes and summaries of care, to guarantee cohesive collaboration among all care providers. This concerted effort ensures smooth transitions and sustained care continuity.
SDOH Screening and Support
Our CCM program checks for Social Determinants of Health (SDOH) like living conditions, income, education, and support networks because they deeply affect health. We then offer help based on what we find, connecting patients with resources like social services, job help, and community programs. This approach helps us care for the whole person, not just their medical needs, aiming for better health outcomes by tackling the broader aspects of their lives.
PCP/ Specialist Referral Coordination
We facilitate referrals to PCP or specialists like cardiologists, oncologists, or physical therapists as part of our comprehensive care strategy, ensuring patients receive the expert care they need.
Navigational Case Management
Our case management services guide patients through the healthcare system, helping them secure appointments with appropriate providers and ensuring they receive the necessary care without delay.
Telehealth Services
We offer telehealth options, including phone consultations, video conferencing, and secure digital messaging, to extend our CCM services. This is particularly advantageous for patients in remote areas or those facing challenges in accessing in-person care.
Connection to Community Resources
Our team assists patients in accessing vital community resources, such as transport services, meal delivery, and support networks, to support their recovery and well-being.
Educational Empowerment
We emphasize the significance of educating patients and caregivers about health conditions, treatment protocols, critical warning signs, and lifestyle adjustments required for effective self-care. This empowerment aids in the active participation of patients and caregivers in the care process.
In-Home Support
When needed, our team conducts home visits to assist patients with daily living activities and provide educational and emotional support to both patients and families, enhancing the home recovery environment.
Caregiver Support
We offer resources and guidance to caregivers, equipping them with the knowledge and skills needed to care for patients with chronic conditions, thereby reinforcing our holistic approach to patient care.
Continuous Follow-up Care
Post-discharge, our team remains dedicated to providing ongoing care through follow-up calls, home visits, or clinic appointments, ensuring patients are supported throughout their recovery.