Care Management

Care Management is an important service that connects communication and coordinates efforts between families, care teams, other healthcare providers. Care Management also helps with hospital discharge or transition between care levels. Areas the Care Management role oversees include nutrition and medication supervision, vital signs tracking, and chronic condition management. This service helps to spot changes in health and decrease returns to the hospital.

What is Included in Care Management Services?

  • Reviewing Vital Signs and Care Notes to help manage care and improve patient satisfaction.
  • Person Centered Care: You provide the direction of care desired for your loved one and we will build a custom care plan accordingly.
  • Chronic Condition Management: We care for those with memory loss, heart failure, COPD, and diabetes.
  • Increased Oversight of Safety Concerns: We assess one’s surroundings to incorporate additional safety measures and home modifications before a crisis takes place.
  • Dedication: The Care Management Team focuses on you and your loved one, with Care Management and customer service being our top priorities.

Care Management Assists Family Caregivers

A Care Manager helps family caregivers navigate the complex healthcare system and ensure that their loved ones receive the appropriate care and support they need.

One way in which Care Management assists family caregivers is by coordinating hospital or rehab discharges. This involves communicating with healthcare professionals, such as doctors and nurses, for a smooth transition from hospital to home. 

Care Management also helps set up additional services such as companion care and personal care services. These services provide support to family caregivers by offering assistance with daily activities such as bathing, dressing, and meal preparation. This not only eases the burden on family caregivers, but also guarantees their loved ones receive the necessary care and supervision.

Case Study: Lorraine

Lorraine, a vibrant 89-year-old who had been enjoying her independent lifestyle, unfortunately experienced a sudden fall which resulted in broken ribs. This unexpected incident caused her immense pain, prompting her concerned family to reach out to her primary care physician for guidance on how they could assist her during this difficult time.

​To their surprise, the physician suggested readmitting Lorraine to the hospital by visiting the emergency room. However, after careful consideration, the family felt that this course of action might not be the best solution for their beloved Lorraine. Instead, they decided to explore alternative options, hoping to find a way for her to receive the necessary care and support within the comfort of her own home.

By choosing to seek an alternative solution, Lorraine’s family demonstrated their commitment to finding the best possible care for her while honoring her desire to maintain her independence.

Care Management | Lincoln | Home Care Partners

The Challenge

Lorraine’s well-being demanded round-the-clock attention, a responsibility that proved to be quite challenging for multiple family members. Inexperienced in health Care Management, they found themselves overwhelmed and deeply affected by the sudden shift in their family dynamic. Recognizing the need for a different approach, Lorraine and her family made the courageous decision to reach out to Karla Frese, a compassionate and knowledgeable senior care advisor at Home Care Partners. Their proactive step sought the guidance of a trusted professional who could assist them in finding a more suitable caregiving solution.

Our Solution

Home Care Partners promptly initiated 24/7 restorative support for Lorraine. Our dedicated Care Management team worked closely with Lorraine’s primary care physician and physical therapy team. By establishing a strong partnership with her healthcare providers right from the beginning, Home Care Partners successfully arranged follow-up appointments with each provider, closely monitored Lorraine’s progress, and proactively addressed any concerns to prevent hospital readmissions. 

The compassionate care team collaborated with a group of providers to effectively manage Lorraine’s pain and facilitated the acquisition of essential medical equipment such as a lift chair and bathroom safety devices. Moreover, our Caregivers received comprehensive training from Lorraine’s therapist, enabling them to assist her with beneficial physical therapy exercises. These meticulous measures play a crucial role in averting unnecessary hospital readmissions and have greatly contributed to Lorraine’s sustained strength and balance.

The Outcome

Home Care Partners offered much-needed respite to the family, enabling Lorraine’s sons to fulfill their roles as loving sons rather than assuming the responsibilities of Caregivers. The remarkable restorative support services provided by the team contributed to Lorraine’s rapid progress, as she regained her strength and was able to walk and stand with the assistance of a walker after just one week! 

As the second week unfolded, her balance showed noticeable improvement, and within a couple of months, Lorraine was able to graduate from the program altogether. Her unwavering motivation, coupled with a dedicated exercise routine facilitated by her compassionate Caregivers, empowered her to reclaim her independence once again.

Our team is not only dedicated to offering exceptional care, but to be your support system. We believe in going above and beyond by not only providing reliable senior home care but also being a source of comfort and assistance for families. We understand the challenges you may encounter, and we are here to help.

Over the past 5 years, Home Care Partners has been fortunate enough to receive multiple awards in recognition of our commitment to excellence. We are proud to have been named a top 3 local business in the highly esteemed Lincoln’s Choice Awards for three years. 

Care Managers Ease Family Caregiver Stress

Care Management provides support and guidance that reduces stress for caregivers.

Family caregivers often feel overwhelmed and stressed by the responsibility of caring for a loved one.

However, Care Management can provide them with relief and support.

One way Care Management eases family caregiver stress is by giving them a full care plan.

Care Managers work closely with the family to evaluate the care recipient’s needs and develop a customized plan to address those needs.

This plan includes help with daily living activities, medication supervision, and coordinating medical visits.

Having a clear plan in place can make caregivers feel more confident in their ability to give proper care and support.

Another way Care Management reduces caregiver stress is through regular monitoring and oversight. Care Managers ensure the care recipient gets the needed care and attention. This can reduce the constant worry and anxiety caregivers feel.

Additionally, Care Management provides education and resources to family caregivers, equipping them with the knowledge and skills needed to provide quality care. 

Care Managers can offer guidance on managing challenging behaviors, dealing with medical emergencies, and accessing community resources. This support and education can empower caregivers and reduce their stress levels.

Providing Care Management in Lincoln, Waverly, Hickman, Bennet, Firth, Malcolm, Hallam, Panama, Roca, Denton, Raymond, Sprague, Davey, and all of Lancaster County.

Frequently Asked Questions About Care Management Services

Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) cover eligible medical home health services (RN, PT, OT, ST) as long as you have a doctor’s order for intermittent skilled services and you’re “homebound,” 
Covered home health services include: 
A doctor or other health care provider (like a nurse practitioner) must have a face-to-face visit with you before certifying that you need home health services. A doctor or other health care provider must order your care, and a Medicare-certified home health agency must provide it.
Medicare doesn’t pay for:
  • 24-hour-a-day care at your home
  • Meals delivered to your home
  • Homemaker services (like shopping and cleaning) 
  • Custodial, personal home care caregiving support that helps you with daily living activities (like bathing, dressing, or using the bathroom)
*Homebound Requirement means that you may leave home for medical treatment or short, infrequent absences for non-medical reasons, like hair appointments and  religious services.

Care Management provides support and education to individuals with various chronic conditions. It ensures proper supervision, prevents hospital readmissions, and coordinates with healthcare professionals. Customized care plans based on the client’s direction are implemented for a clearer understanding of their health situation.

Care Managers may recommend home modifications such as installing grab bars in the bathroom, removing tripping hazards, improving lighting, adding handrails on stairs, and implementing a medical alert system for the safety of clients.

Care Managers communicate with healthcare professionals by coordinating care, sharing information, and ensuring a smooth transition for the client. They collaborate to provide the best possible care and support for the client’s needs.

Proactive healthcare measures taken by Care Managers utilizing electronic care notes include monitoring vitals, managing medications, addressing health declines, and improving patient care. These measures enable timely interventions and enhance patient satisfaction.

Care Managers ensure a truly customized care plan by actively listening to the client’s needs and preferences, conducting thorough assessments, and collaborating with the client and their healthcare team to develop a plan that meets their unique requirements.

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