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HomeHealth ServicesCase Management

Health Services

Case Management

Why Would I Need Case Management?

The need for case management services is determined through a collaboration between you, your family or caregiver, your health care team, and your provider. This collaboration will include a comprehensive assessment of your health, psychosocial needs, and use of health care services and resources.

Case management can help by:
• Coordinating your care.
• Assessing, planning, and facilitating services for you.
• Evaluating your options.
• Advocating on your behalf.

You or your family member may need case management if you have:
• Instability with chronic health problems
• A serious terminal illness
• An increased need for different provider specialties due to multiple diseases or conditions
• A need for more support and education during a critical period

Who are Case Managers?

Case managers are usually nurses or social workers who can help you and your family figure out complex health care and support systems. They will work with you to coordinate the services and other community resources you need

They can help:
• Provide advocacy, support, and education
• Reduce burden and streamline appropriate utilization of care
• Partner with members of your healthcare team to assist in coordination of your healthcare needs
• Monitoring for progress and desired outcomes

Case Management/Discharge Planning

The NMCP Case Management team is staffed with over 30 RN’s with years of case management and discharge planning experience and knowledge. Our team supports the Medical Home Clinics, specialty clinics and outpatient wards to provide support to our patients and collaboration with our medical providers and ancillary staff.

Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost effective outcomes. (CMSA, 2010).

Case Managers ensure appropriate access to quality care and to promote care that is safe, timely and cost-effective by maximizing the available resources. The Case Manager must also interject objectivity and information where it is lacking, advocate for the patient when necessary and work collaboratively with the patient, family and/or interdisciplinary team to develop and implement a plan of care that meets the patient’s individual needs.

Discharge Planning is a collaborative effort between the discharge planner and the health care team which includes the physician, patient, family caregiver, ancillary services, and other involved parties to assist in transitioning the patient to the next level of care without compromising quality.

The discharge planners incorporate the patient’s post-hospital care preferences, needs, the patient’s capacity for self-care, an assessment of living conditions, and the identification of health or social care resources to assure high-quality post-hospital care.

Who can refer to Case Management?

ANYONE can refer…. Self, family, doctor, other ancillary providers can refer for services. ALL referrals will be reviewed by a member of our team to assess appropriate criteria.

Case Management Services

Patient Feedback

Case Management Comment Card

Discharge Planning Comment Card

Phone

(757) 953-7500

Pager (Weekends and Holidays)

(757) 860-5441

Location

Charette Health Care Center
Building 1, Room C208

Hours

Discharge Planners On-Call
Monday through Friday 7 a.m. -4:30 p.m.
Weekends and Holidays 8 a.m. -4 p.m.

Availability of Services

Case Management & Discharge Planning Services

Appointments

Referral Service
Don't forget to keep your family's information up-to-date in DEERS.