Care Transitions is the movement of patients between one care setting or care provider to another. This can be from hospital to community or from acute hospital to a rehabilitation facility.

Care Transitions includes hospital bedside visit prior to discharge, home visit post-hospitalization, care coordination of service, including medication review and arranging for visit with primary care provider within one to two weeks of discharge.

Call (833) 673-9355 for more information.

Chronic Care Management (CCM) is defined as any care provided by medical professionals (and their health care team) to patients who have chronic diseases and conditions. In the United States, CCM refers to the chronic care services provided to Medicare beneficiaries with more than one chronic condition.

CCM involves a comprehensive care plan that includes a record of the patient’s chronic conditions, personal information and goals, health care providers, medications, and any other services needed to manage their condition.

Call (833) 673-9355 for more information.

Options Counseling is an interactive decision-support process where community members, family members, and/or significant others are supported in their deliberations to determine appropriate long-term care choices given the community member’s needs, preferences, values and individual circumstances.

Options Counseling might be provided to an individual who wants to remain in their own home but needs support to do so, after someone has been admitted to a long-term care facility, or when a family caregiver needs help to continue providing care.

Please call (833) 673-9355 for more information.

Call (833) 673-9355 for more information.