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Care Management

Empowering your healthcare journey with expert guidance, personalized care, and solutions you can trust.

Transitions of care occur when a patient moves from one healthcare setting to another—such as from a hospital to a long-term care facility (LTC), assisted living facility (ALF), primary care provider (PCP), or specialist. These transitions are critical points in a patient's healthcare journey.

 

When not managed effectively, transitions of care can lead to medication errors, miscommunication, unnecessary hospital readmissions, and increased healthcare costs. Ensuring clear communication, accurate medication reconciliation, and coordinated care during these transitions is essential for improving patient outcomes and reducing the overall burden on the healthcare system.

Transitional Care Management

Our Transition of Care Support Includes:

  • Interactive Communication
    Provide face-to-face and non-face-to-face interactions with the patient and/or caregiver to ensure clear understanding and coordination of care.

  • Discharge Information Review
    Carefully review discharge instructions to clarify medical information and ensure continuity of care.

  • Medication Reconciliation
    Compare the patient’s medication lists before and after the transition to identify and resolve discrepancies.

  • Follow-Up Planning
    Reinforce and review follow-up care instructions to support adherence and reduce the risk of hospital readmission.

  • Healthcare Coordination
    Communicate and collaborate with physicians, specialists, and other healthcare professionals to ensure a seamless care experience.

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Medication Therapy Management

Individual Medication Therapy Management (MTM) Services

Our Medication Therapy Management services are delivered by a licensed pharmacist and include both face-to-face and non-face-to-face consultations. These personalized sessions involve a comprehensive assessment of your medications and interventions as needed to optimize your health outcomes.

 

Our MTM services include:

  • Patient Education
    Empowering patients and caregivers with knowledge about medications, conditions, and treatment goals.

  • Medication Reconciliation
    Ensuring accuracy of medication lists across care settings to prevent errors or duplications.

  • Drug Regimen Review
    Evaluating all medications for effectiveness, safety, interactions, and appropriateness.

  • Problem Intervention
    Identifying and resolving actual or potential medication-related problems.

  • Medication Adherence & Persistence
    Supporting patients in taking medications correctly and consistently.

  • Disease Management
    Collaborating with patients and providers to manage chronic conditions more effectively.

  • Comprehensive Medication Management (CMM)
    A holistic, ongoing approach to ensure each medication has an appropriate indication, is effective for the condition, safe for the patient, and able to be taken as intended.

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Chronic Care Management

In partnership with healthcare providers, we offer a structured and comprehensive documentation of the patient’s health information. This process supports the development of an individualized care plan designed to address the patient’s unique needs and improve health outcomes.

Our care planning services include:

  • Identification of All Health Issues
    A complete assessment to ensure all current medical conditions are recognized and addressed.

  • Facilitated Access to Care Management Services
    Connecting patients with appropriate services and resources to support ongoing care needs.

  • Management of Care Transitions
    Coordinating smooth and safe transitions between care settings (e.g., hospital to home, or primary care to specialty care) to reduce gaps in care and prevent complications.

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                          Interested in getting advice improving Care Management Services?                                 Call me today and see what I can do for you.

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