CARE MANAGEMENT SERVICES INCLUDE but not limited to:

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

At Selective Medical Services, LLC we offer various care management programs all based on provide the above services in a structured model including telephonic, short and long term in-home care manager visit. The frequency of in-home visits is 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 call within 30 days of discharge from the hospital

At the end of the 30 day episode, the patient will either be discharged successfully from program or converted to the Chronic Care Management Program

CHRONIC CARE MANAGEMENT PROGRAM

Focused on patients with long term chronic health problems at higher risk of hospitalization.

Consists of weekly or bi-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.

Re-assessment of a patient’s need to participate in our Chronic Care Management Program will be done every 3-6 months.

  • Visit can take place in a facility if needed.

TELEPHONIC CARE MANAGEMENT

Focused on telephonic support to utilize evidence-based tools to identify patients risks for hospitalizations.

Patients participating in the Telephonic Management Program can be referred for a One Time High Risk Assessment if indicated

ONE-TIME ASSESSMENT 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.

*High Risk visits may also be conducted if the Telephonic CM has concerns for the patient’s safety.

 

Contact Us

We're not around right now. But you can send us an email and we'll get back to you, asap.

Not readable? Change text.