In the role of Complex Care Manager, our team of registered nurses collaborate with the patient’s primary care providers, specialists, and insurer to meet the health and wellness needs of patients with multiple health conditions such as poorly controlled Diabetes, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure (direct link to Heart Failure Health Management plan in Patient Resource tab), End Stage Renal Disease, and Mental Health conditions. Nurses initiate telephonic outreach calls to patients at home and review the 90-day program.
Within the three-month period, patients receive a minimum of 1-2 sessions each week in the first month, 1-2 sessions in the second month, and a referral to the community health worker and a wrap-up session with the nurse in the third month. Included in sessions with each patient is educated on the disease process, identification, and communication of patients goals of care, a review of the prescribed, individualized plan of care, discussion of evidence-based approaches to preventive care strategies and management, identification and coordination of Gaps in Care, as well as reinforcement and coordination of follow-up services. Risk factors are highlighted, in addition to, signs and symptoms, identifying triggers to avoid, and crisis management. Referrals are made to community health workers, social workers, pharmacists, or outside agencies as requested by the patient, as part of our standard care coordination services, toward meeting health and wellness goals.
The complex care management program has shown to help improve disease management and reduce the risk of hospitalizations and readmissions.