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Care Management improves care by helping patients navigate the health care system and manage their health care needs. PSW makes available a variety of care management services for its Medicare Advantage members.

Case Management is provided over the phone, at the clinic, in the hospital and even at home. Services are provided by a team comprised of Care Navigators, Nurses, a Social Worker and guided under the supervision of a Medical Director. All services provided by PSW will be closely coordinated with Primary Care Providers.

[accordion title=”victor saltem non semper” color=”blue”]Care Management Services[/accordion] [accordion title=”Ut heri fuisse caseum ” color=”blue”]Urgent Care List[/accordion] [accordion title=”Comprehensive Case Management (CCM)” color=”blue”] Patients often benefit by having help accessing health care referrals, health education, advocacy and coaching for chronic health conditions. PSW’s trained health care professionals, including nurses and social workers, can provide these services by phone or in person at a provider’s clinic or patient’s home.
[/accordion] [accordion title=”Vitulus misit super” color=”blue”] Vitulus misit super stellarum, unde arcus centenis ire? Dixit autem roseo colore respersa caseum centenis video viro loquitur luna. Quae est trans locum satis lux lunae. Vidistine ubi posuerunt. Etiam non est. Post tres dies hesterna post cras. Et pergens ad reprimendum et posuit illud super ripam nunc. Hodie recte puto. Ut heri fuisse caseum cum est homo super terram moonbeam.
[/accordion] [accordion title=”Care navigators” color=”blue”] Care navigators support providers and patients in understanding health plan coverage and helping to provide the best possible care and service for the patient. Care navigators serve as a liaison between the patient and their support network. Navigators can facilitate referrals, provide appointment scheduling, identify and connect the patient to needed care resources, and more.
[/accordion] [accordion title=”Skilled Nursing Facility (SNF) direct admission” color=”green”] Medicare Advantage patients, who need rehabilitation or care, but not hospitalization, can be admitted directly to a skilled nursing facility. Direct admission to a skilled nursing facility can ensure patients receive quality care at the right time and at a reduced cost, and may help avoid unnecessary wait times or hospital visits. PSW staff can answer questions and assist with the referral required for direct SNF admission. For providers: Learn how to request a SNF direct admission

[/accordion] [accordion title=”Remote Patient Monitoring (RPM)” color=”dkblue”] PSW initiated a program called the Remote Patient Monitoring program (RPM) to help patients improve their health and decrease emergency room visits and acute patient hospitalizations. PRM allows early identification and outpatient treatment of CHF/COPD patients at early stages of decompensation/exacerbation. RPM is a patient monitoring program that includes the collection and transmission of clinical data between a patient and monitoring agency using cellular or “land line” telephone technology.  PSW focuses its efforts on beneficiaries who would benefit from  improved understanding their CHF or COPD disease process, and support to manage signs and symptoms to reduce utilization of emergency room and inpatient stays  PSW uses a contracted agency to review all transmitted information and compiles a clinical review of the data, contacts the patients and provides responses where needed.

[/accordion] [accordion title=”Advance Care Planning” color=”dkblue”] Planning for care at the end of life and understanding a patient’s wishes about personal health care—before he or she becomes unable to express these wishes—is a critical part of patient care. The PSW team encourages patients, family members and providers to work together to make a plan for end of life care. Our CCM program can help facilitate this process. As part of this service, PSW staff support patients and caregivers in preparing a valuable, non-legal document that will help patients describe what good care means to them. Whether or not a patient is seriously ill at present, advance care planning ensures that others know and understand exactly what he or she wants. Patients can enroll in CCM at any time. No referral is required and there is no additional charge.

[/accordion] [accordion title=”Medicaid Enrollment”] Many patients who are eligible for Medicaid do not know how or where to enroll. PSW care management staff members are very experienced in navigating the regulations and complexities of this process. We can determine if a patient meets dual eligibility requirements for Medicare and Medicaid and can help patients complete the enrollment process.[/accordion]

About the PSW Care Management Department

Our team includes:

  • Medical directors
  • Care Management director
  • Nurse case managers
  • Physician Advisory Committee
  • A Quality Improvement and Medical Management Committee

Contact the PSW Care Management Department

Weekdays: 360-786-8690
Weekends: 360-742-4149
Fax: 360-786-8751
Email: [email protected]

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