Since 2018, Complete Family Care has provided care management services to our patients. Chronic Care Management (CCM) services play a crucial role in primary care services, contributing to better patient health and care. Care management services are typically provided outside of face-to-face visits and focus on furnishing services for continuous patient-provider relationships. To better serve the needs of patients with chronic conditions and those that will transition from a facility, Complete Family Care has a team dedicated solely to developing and supporting a comprehensive plan for care.
CCM
Emily, RN: After joining the practice in the fall of 2021, Emily quickly began taking an active role in expanding our CCM services. Emily provides continuity, collaborating closely with the patient’s primary care provider to ensure continuous care with the patient’s dedicated primary care provider. Emily ensures information is coordinated between the practice and any outside specialty providers. She collaborates directly with each patient to establish goals and barriers which are tailored to assess the functional and medical needs for improvement in overall healthcare outcomes. Emily will provide recommendations for preventive services, making sure gaps in care are closed.
TCM
Jessi, RN: Jessica joined the practice in July 2021 and provides transitional care management services (TCM). Part of Jessi’s role is to track hospital admissions and anticipate the needs of the patient upon discharge based off facility information and connecting directly with patients after they are released from the inpatient setting. She works to ensure that the patient’s provider is aware of the hospital admission, what transpired while in the hospital and what the patient will need when they come into the office for their scheduled follow-up.
Outreach Services
Janice, Outreach Coordinator: Although Janice recently joined the team in 2023, she has an extensive background that supports the growing needs of our patient population. As a local resident of the area, she has plenty of knowledge and experience with Community Based Organizations and can connect patients with the appropriate resources for their needs. Circumstances that may impact the patient’s overall health and wellbeing are Janice’s focus, so she will provide a warm hand off to patients in need of resources like transportation, housing, food etc. Janice provides education on preventive services and guides patients to get those gaps in care closed.
If you are interested in any care management services, please reach out to the practice and someone would be happy to answer any questions you have. |