CARE MANAGEMENT SERVICES

CARE MANAGEMENT SERVICES INCLUDE BUT NOT LIMITED TO

  • nurse care managementReferring members to meal delivery programs and advance directive preparation services.
  • Assessing the member’s daily living activities and cognitive, behavioral and social support.
  • Monitoring medication adherence.
  • Arranging access to transportation.
  • Assessing the member’s risk for falls and providing fall prevention education.
  • Connecting members and their families with professionals who can help them address concerns.
  • Assist clients in obtaining help regarding medical, legal, housing, insurance and other areas in which they have a need or interest.
  • Assisting members in obtaining home health and durable medical equipment.
  • Helping caregivers access support and respite care.
  • Facilitating conference calls between the member, the physician and the care manager as needed to clarify treatment plans, medication regimens or other urgent issues.
  • Chronic conditions addressed by this program include chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease and diabetes.

 

At SOL Health, LLC we offer various care management programs all based on providing the above services in a structured model including telephonic, short and long term in-home care manager visits. The frequency of in-home visits can be determined by the individualized plan of care.

 

30 DAY TRANSITIONAL CARE (AFTER HOSPITALIZATION)

Focused on patients recently hospitalized related to a new onset of acute illness, ongoing unmanaged chronic condition or injury. Consists of 3 in person care manager visits in the patient’s home and 3 phone calls within 30 days of discharge from the hospital. At the end of the 30-day episode, the patient will either be discharged successfully from the program or converted to the Chronic Care Management Program.

CHRONIC CARE MANAGEMENT PROGRAM (Long-term):

Focused on patients with long term chronic health problems at higher risk of hospitalization. Consists of weekly in-person home visits by the assigned care manager. Care Manager will continue to follow patient until empowerment of self-managing healthcare needs are achieved or patient’s status changes, such as hospice or palliative care. Visit can take place in a facility if needed.

ONE-TIME (IHS) In-home Survey FOR HIGH-RISK PATIENTS:

Patients are referred by the Telephonic Care Manager if it is determined the patient may be at risk for hospitalization or in need of an in home assessment to evaluate and determine an individualized plan of care.

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