Community Outreach Services
A multifunctional assessment will tap the patient/caregivers abilities.
1) We will contact the client by phone to schedule case management home visit. We will explain our case management services and the purpose for the visit. If unable to reach the client by phone. We will send a second Case Management Introduction letter, and outreach services will be initiated to contact the client.
2) The case manager will perform a multi-functional assessment with the patient/caregiver in the following areas:
· Functional Ability
· Financial Status
· Physical Health
· Medication Profile
· Psychosocial Health
· Environmental Factors
Care Plan of Care
Based on the individual assessment of identified needs and patient/caregiver input and approval, the case manager develops the care plan. The care plan includes specifics interventions to address the patient’s needs identified on the patient list.
1) All population support services
2) Community outreach by face to face interventions and monitoring
3) Medical appointment scheduling and monitor
4) Arrangement for support services such as medical equipment, nursing care & transportation
5) Nutritional monitor for intake and weight
6) Monitoring of laboratory data and other diagnostic test
7) Patient and family education
8) Timely follow-up
9) Crises intervention
10) Outreach referrals
11) Episodic management
12) Immunization follow-up
Case Management is typically triggered by the onset of crises, illness or injury
Referrals are by physician, other health care clinicians, or are community based.
1.) Referrals can be made by anyone including:
b. Other healthcare clinicians
c. Family member
d. Community resources
e. Emergency rooms
2.) A physician approval is usually obtained for participation in our clinical case management program. Other arrangements & approvals are made by the criteria of the community based program.
Newborn/Pediatrics Case Management
Pediatrics Case Management will follow children ages 0 to 18 who will meet the following high-risk population criteria:
1) New born assessment
2) Premature infant with birth weight <2,500 gm
3) Very low birth weight <1,500 gm
4) Pre-term <35 weeks
5) Positively toxicology screen infant
6) Neonatal drug addiction
7) Fetal Alcohol Syndrome
8) Failure to thrive
9) Home on monitors Apnea/Cardiac
12) RH incompatibility
13) Siblings with history of SIDs
14) Burns (thermal or frostbite) involving >10% of the body
15) NICU L.O.S. >5 days
16) Child HIV + and/or with AIDS related complex, child born to mother with these, related disorder and sequelae
17) Cytomegalovirus (CMV)
18) Re-admissions, 2 or more hospitalizations or ER visits in 60 days
19) Neurological problems (seizures, Cerebral Palsy, etc.)
20) Noncompliance, >2 occurrences in 4 months with high-risk diagnosis
21) Children with chronic diagnosis
22) Sickle cell disease
23) Hospitalized for lead poisoning
24) Elevated blood lead level
We believe that we can impact our community through case management. We will be empathetic and non-judgmental during client contract.
Case Management takes integrated patient/caregiver approach to coordinating patients’ needs over a period of time. Our service is performed by delivering care (health, teaching, monitor, support) and cost-effective community-based services to maintain the most appropriate patient environment.
Our case management process is to provide screening, assessment, care planning and coordination of services, monitoring, while consistently reassessing the needs and service to meet the patients’ optimal health outcome. Patients managed by us include adult and pediatric population, mental health, OB, Maternal health, high risk, prenatal, infants and children with special needs, and other specialties requiring intervention.