Nurse care managers are key collaborators on the team. They assist with adherence and provide at-home support to ease transitions and reduce 30-day readmission.
Refer a patient when
- you have concerns about discharge. Some home situations are not fully prepared to handle the increased needs of a recently discharged family member. Relatives may live far away. A spouse may have his or her own health challenges. We can assess the situation and put safeguards in place to safely ease the transition.
- medication management is an issue. Especially if the patient is struggling with memory problems, our trained staff can implement strategies to improve adherence and help patients (and families) adjust to new regimens.
- multiple comorbidities or polypharmacy make for a complex medical situation. We can be your eyes and ears by monitoring at home on a regular basis and catching a problem before it results in an emergency room visit.
- dementia is a concern. By attending appointments with your cognitively impaired patients, we can ensure that you hear about the top-priority symptoms and that treatment recommendations are understood and implemented by caregivers in the home setting.
- family members frequently call for updates. We save you time by using our existing connections to communicate with the network of relatives.