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.