CARE MANAGEMENT AND TRANSITION OF CARE SERVICES

Care Management

Our Care Management team includes a Registered Nurse, care coordinators, and medical social workers who provide a more comprehensive level of care and assist our patients to navigate the increasingly complex healthcare system.

Goals of Care Management:

Assist in communication between you, your primary care physician, and your specialists.

Assist with access to medical care, including home and community services and medical equipment.

Develop a personalized care plan for each patient

Chronic Disease Management (for example, COPD, heart failure, diabetes)

Coordinate care after hospitalization

Support in making healthcare decisions including goals of care and Advance Care Planning to complete Living Will and Healthcare power of attorney documents.

Transitions of Care

Our team is notified immediately if you are hospitalized and will reach out to you and your caregivers to help coordinate a smooth transition for discharge.

Assist in communication between the hospital team, primary care physician, and caregivers.

Assist with community resources like home health and medical equipment

Review your medications

Help you and your care team stay connected including scheduling follow-up appointments.

IMPORTANT!

IMPORTANT! All information presented in this website is intended for informational purposes only and not for the purpose of rendering medical advice. Statements made on this website have not been evaluated by the Food and Drug Administration. The information contained herein is not intended to diagnose, treat, cure or prevent any disease.

ADDRESS:

1730 Southgate Parkway,
CAMBRIDGE, OH 43725

CALL US: (740) 435-3333

FAX: (740) 435-8583