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.
- Advanced Directives
- Providing community resources and encouraging participant to engage in social outlets.
- Advocate family member participation.