Care Management for Seniors
This service is for contracting practices, Primary Care Providers, Accountable Care Organizations, and Health Plans.
It is difficult to keep track of health conditions across providers, as well as schedules, medications, and appointments. Community Care of the Lower Cape Fear's Care Management service is designed to assist patients and their support systems (including the providers involved with their care) in managing multiple health conditions more effectively.
Care Management refers to a comprehensive suite of services that assist patients and providers with Chronic Care, Transitional Care, and Annual Wellness Visits. These Care Management Programs are for Medicare patients dealing with two or more chronic conditions.
Care Management for Seniors
This service is for contracting practices, Primary Care Providers, Accountable Care Organizations, and Health Plans.
It is difficult to keep track of health conditions across providers, as well as schedules, medications, and appointments. Community Care of the Lower Cape Fear's Care Management service is designed to assist patients and their support systems (including the providers involved with their care) in managing multiple health conditions more effectively.
Care Management refers to a comprehensive suite of services that assist patients and providers with Chronic Care, Transitional Care, and Annual Wellness Visits. These Care Management Programs are for Medicare patients dealing with two or more chronic conditions.
Chronic Care Benefits
- Telephonic support provided per current CMS Chronic Care Management guidelines
- Providing communication and documentation for “Continuity of Care”
- Comprehensive care plan and management of chronic illness
- Communication of care transitions with all providers involved in patient care
- Coordination of home and community-based services (Home Health and Hospice)
- Documentation support within your Electronic Health Record
- Patient education and Advance Care Planning / Directive Review
Wellness Care Benefits
- Additional support staff in the clinic setting per CMS “Annual Wellness Visits” guidelines
- Conduct health risk assessment
- Advance Care Planning education and completion of Directives
- Establish a preventative screening schedule
- Comprehensive patient and family history
- A list of providers and suppliers involved in care of patient
- Assessment of cognitive function, safety risk, mental health disorders, and other mood disorders
Transitional Care Benefits
Hospital to home support per current CMS and transitional care management guidelines
- Telephonic support by a Care Management RN (20-25 days) post discharge to assess patient stability and to potentially decrease readmission to acute settings
- Education for patient and caregiver on discharge instructions
- Support services to manage follow-up appointments and testing
- Communication to provider on medication coordination as well as reconciliation, along with a monthly report to clinic billing office for billing purposes
- Telephonic support by a Care Management RN (20-25 days) post-discharge to assess patient stability and to decrease readmission to acute setting
Benefits for Providers
Elements of Care Management benefits for Providers in the clinic setting:
- Improve clinical outcomes
- More preventive care visits
- Higher Patient satisfaction
- Reduced use of high-cost acute care
- Increase revenue
- Fewer duplicative test and procedures
Benefits for Patients
- Increased education
- Additional support
- Increase connection to support services