Care Management

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.

Care management is about helping health care providers and their patients manage medical conditions as effectively as possible. PSW offers post-discharge visits support patients who need transitional care after a hospital discharge. The goal is to reduce hospital readmission by offering needed care at home, helping the patient recuperate safely in the days and weeks following a hospitalization. PSW’s trained staff members evaluate each patient’s circumstances to determine the transition support needed and coordinate efforts with the patient’s primary care provider, if applicable. Post-discharge home visits are a covered benefit in most cases.

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.

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

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. RPM 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 an improved understanding of 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.

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. Watch our ACP video by clicking here.

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.