Home Health Care and Care Management

The Chronic Care Management team assists in building a team-based approach with the Physician, Home Health Agency, Patient and Family. We strongly encourage self-management skills and assist in goal setting to help the patient manage their condition.  

Our Home Health Care goals are to: 

• increase the patient’s quality of life.
• decrease Hospital and Emergency Department visits
• decrease medical expenses

Care Management Services

Care Management team members work very closely with local Home Health Agencies when patients are found to be in need of services. Services include, but are not limited to: Nursing Services, Physical & Occupational Therapy Services, Wound Care Services, Social Work Services, and overall monitoring of health status.

We look at the following criteria when providing patients information on Home Health Agencies to select from:

1. Are they able to keep patients at home versus sending them to a hospital
2. What is the patient spend (cost to the patient)?
3. Are they known for excellent patient quality based on Medicare Star ratings?
4. How are they at communicating with the Chronic Care Management team members and physician’s office?

When do we recommend Home Health Care?

1. After a recent hospitalization, rehab stay
2. Recent medication changes or misunderstanding of medications
3. Overall decline in function
4. Patient assessment finds the need for Home Health Care (some examples are: recurrent falls, dementia/confusion, limited mobility, weakness that limits the ability to safely ambulate long distances beyond the home)

Home Health Agencies work with our Care Managers on a regular basis and communicate their findings directly to the Care Manager who will then address the need/issue in a timely fashion.

If you feel that you or your loved one meet any of the above recommendations or would like more information, feel free to reach out a member of the Care Management Team or speak with your Physician today!