Care Management and Coordination

Care Management and Coordination

MACIPA’s Care Managers/Care Coordinators work closely with our physicians to provide additional individualized support for patients, when they are hospitalized, in a skilled nursing or rehabilitation facility and for the chronically ill and frailest of patients in their homes. Care coordinators are Registered Nurses who work with physicians to facilitate and coordinate the patient’s discharge from the hospital. They ensure the patient is ready to be discharged, has a follow-up appointment with their physician shortly after discharge and that the patient understands instructions about medicines, follow-up care, or whether home care services or equipment are needed. If home care services are needed, the Care Coordinator will arrange it. Patients discharged from the hospital to a skilled nursing facility will be followed by a Care Coordinator until discharge and at home, when needed.

MACIPA has systems that identify which patients are the sickest and frailest and assigns Care Coordinators to contact these patients. The Coordinator assesses how the patient is doing at home, if there are social as well as medical needs, or problems with medications. The Care Coordinators communicate with the patient’s physician, keeping them informed of how their patients are doing between doctor visits. The Care Coordination services we offer are a critical part of the services we provide.

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