Care Management: our goal is to improve the participants’ overall health awareness and limit exacerbation of acute and chronic illnesses with the measurable outcome of a decrease in hospitalizations and ER visits.
Establishing trust with participants for full engagement allowing for transparency regarding their healthcare needs.
Identifying socioeconomic programs that the participant may qualify.
Providing liaison support with their interdisciplinary team including but not limited to the pharmacist, dentist, primary care physician, and therapy.
Assessing home environment and assisting the participant with resources to maintain safety and independence within the home environment.
Education regarding disease process, medication reconciliation and diet.
Providing community resources and encouraging participant to engage in social outlets.