The Nurse Case Management Team collaborates with primary care practices and the interdisciplinary care management team to provide comprehensive care and coordination for complex patients. Other practices include reducing care fragmentation, and preventable utilization as well as to increase patient knowledge and self-management of disease.

Services

  • Support, education and coordination of care during transitions of care
  • Provide complex case management
  • Collaborate with primary care providers to support disease management
  • Identify and address barriers to care
  • Evaluate factors that may influence a patients ability to self-manage disease
  • Provide self-management education and support
  • Develop personalized care plans and proactively follow patients over time
  • Coordinate care with primary care practices, specialists, hospital teams, and our interdisciplinary care management team of pharmacist and social workers
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