• Medical navigation
• Organize options and services
• Manage transitions of care
• Medication review and reconciliation
• Long Term Care (LTC) policy management
• Estate planning meeting preparation and guidance
• Guidance, coordination and oversight of: Nursing Home, Rehabilitation, Assisted Living, Hospital and Home
• Hospice and end of life decision support/Advanced Directives
• Prevention and wellness education
• Medical transportation
• Coordinate Medical Record
• Communication and collaboration support
• Coordinate and manage resources
• Medication management
• Navigate electronic medical records
• Accompany to provider appointments
• Supportive services around acute hospitalization & elective surgery or procedures; pre-operative
coordination, post-operative hospital, and post-discharge at current site of care
• Collaborate and partner with physicians and other healthcare providers
• Guide, assist and arrange for optimal living arrangements
Through adherence to ethical, legal, accreditation, certification, and regulatory standards my practice is guided by the Nursing Code of Ethics & The Nurse Practice Act and CMSA Case Management Guidelines.
- I offer a FREE Initial Consultation
- I offer TeleAdvocacy Service
- I am insured
- My geographical area of practice is Massachusetts, Connecticut and remote situations throughout New England and nationwide
I coordinated care planning meeting between the ICU and our unit teams which had never been done before. Met with the patient and families several times prior to them being transferred to our floor, which was a new concept. I was young and could not understand why this never happening before. Clearly, in doing so, It had many benefits such as enhancing communication, decreased family/individual stress and allowed for an overall smoother transition to the next phase of care. I always loved doing thorough chart reviews/assessments, and often found incorrect or missed information. Doing these activities helped to establish a more comprehensive plan of care. I even toured rehabilitation facilities with families, sometimes hours away. And of course developed the list of questions for the family to ask and educated them on what to look for.
At that time, Case Management was just being recognized as a profession and when I left the hospital, I became the first case manager in the post-acute industry (then called sub-acute) in all of New England. I was already an Advocate as outlined in practice and ethics standards, but realized that I too was a natural case manager.
The Case Management Society of America's definition of Case Managers is to help provide an array of services to help individuals and families cope with complicated situations in the most effective way possible, thereby achieving a better quality of life. They help people to identify their goals, needs, and resources. The case manager and the client work together to formulate a plan to meet those goals. The case manager helps clients to find resources and facilitates connection with services. She or he advocates on behalf of a client to obtain needed services. The case manager also maintains communication with the client to evaluate whether the plan is effective in meeting the client's goal.