ACM Complex care management provides coordinated and comprehensive approach to address the needs of individuals with multiple, chronic, and often interconnected health conditions. Our staff collaborates across various healthcare disciplines to provide holistic care that addresses medical, psychological, and social aspects. Complex care management aims to improve patient outcomes, enhance quality of life, and reduce healthcare utilization by focusing on personalized and integrated interventions.
Key components of our complex care management include:
- Interdisciplinary Collaboration: Medical professionals, mental health specialists, social workers, pharmacists, and other relevant experts collaborate to design and implement comprehensive care plans.
- Patient-Centered Approach: Care plans are tailored to individual patient needs, considering their medical conditions, psychosocial factors, preferences, and goals.
- Care Coordination: Efficient communication and coordination among healthcare providers ensure that all aspects of a patient’s care are aligned and optimized.
- Health Information Technology: Utilizing electronic health records and data-sharing platforms to facilitate seamless communication and tracking of patient progress.
- Continuous Monitoring: Regular assessments help in identifying changes in the patient’s health status, enabling timely adjustments to treatment plans.
- Medication Management: Ensuring that patients are taking medications correctly and understanding potential interactions, side effects, and benefits.
- Patient Education: Empowering patients to manage their conditions by providing them with information about their health, treatment options, and self-care strategies.
- Social Determinants of Health: Addressing factors such as housing, transportation, access to healthy food, and support systems that can impact a patient’s ability to manage their health conditions.
- Transition of Care: Smooth transitions between different care settings (e.g., hospital to home) to prevent gaps in care and reduce the risk of complications.
- Outcome Measurement: Tracking patient outcomes, satisfaction, and healthcare utilization to assess the effectiveness of the complex care management approach.
ACM Complex and Chronic Condition Case Management provides the following services:
- Heart failure
- COPD/asthma
- Chronic cardiovascular condition such as CAD
- Chronic neurological impairment such as Stroke
- Chronic Renal Failure
- Disease management
- Member/family education
- Assessment and care planning for various chronic medical/behavioral health
- Behavior modification
- Resource connection
- Member advocacy