Long-Term Care Management
ACCM operates both remote and home-based long-term care management programs. The goal of both models is to improve quality of life for the patients we serve, while reducing unnecessary visits to the ED and in-patient settings.
Through ACCM’s remote model, patients enjoy regular communication and support from Care Managers who are either Licensed MasterSocial Workers (LMSW) or Registered Nurses (RN). This dedicated, bilingual team of care managers works closely with patients, their families and physicians, to ensure the patients’ healthcare needs are being met and that they can continue to live safely and independently in their homes and communities.
ACCM Care Managers and medical staff creates a custom care-plan for each patient, after a careful review of electronic medical records (EMR) to determine the duration and type of home health services that are appropriate for each; we manage authorizations with the Payer(s) as well as communication with the home health agencies. In addition ACCM coordinates with pharmacies and providers to ensure that each patient receives supplemental medical equipment, medications and other resources/supports that will help to optimize their long-term care. This remote-engagement also incorporates monthly wellness-calls to check-in with patients, answer questions, and provide preventive care education and coping strategies (i.e. nutrition, exercise, accessing community resources, preventing falls, etc.) as well as disease education that is specific to their health conditions and needs.
ACCM’s Home-based long-term care management program is an option for those patients who need, or will benefit most from, face-to-face contact with their Care Manager. Once matched to a patient, that Care Manager will generally maintain a relationship with that particular individual, enabling a higher level of accountability and helping to establish trust. All Care Managers possess a Bachelor’s Degree as well as 2-years of experience working with adults in a community-based setting; most also have experience working with patients with chronic disease(s). The care-management team, which also includes a RN and a LCSW, determines the frequency and type of engagement - visits may be needed only on a monthly basis, or as often as several times per week. The substance of a typical visit may be as simple as discussing how to refill a prescription or reduce risk of injury in the home, to accompanying the patient to the Social Security office to renew benefits or traveling with the patient to the pharmacy to pick-up a prescribed heart-rate or glucose monitor.
Through patient-education, assistance with medication management, direct navigational assistance and coordination/communication with a patient’s provider(s), both of these LTC models help to ensure patients remain healthy, in their own homes and out of the hospital.
Contact ACCM today and learn how we can customize a program to meet the needs of your patients and organization.