Nurse Care Managers

  • Chronic disease education and management.
  • Coordination of patient transitions from the hospital or skilled-nursing facility to home care.
  • Medication review and education.
  • Comprehensive patient assessments.
  • Clinical support and outreach for homebound patients.
  • Community resource referrals.
  • Motivational interviewing.
  • Assistance with end-of–life care and planning.
  • Assistance with non-adherence behavior management.
  • Identification of behavioral health and poly-pharmacy concerns.

Integrated Care Partners