Nurse Care Management

Our Registered Nurse (RN) Care Managers collaborate closely with primary care providers to deliver personalized support, education, and guidance to patients facing complex medical challenges. Whether a patient requires short-term assistance, is managing a chronic condition, or is transitioning from a hospital stay, our RN Care Managers are here to help—by phone, in person at medical appointments, at home, and when needed, in the hospital.

Comprehensive Care Management by Registered Nurse Care Manager

Bridge gaps in care

Enhance patient understanding and self-management

Prevent avoidable emergency room visits and hospital readmissions

Reduce administrative burden on primary care practices

Key Focus Areas

Medication adherence and education

Fall risk reduction

Caregiver support and resource identification

Goals-of-care conversations

Coordination of referrals to Visiting Nurse Associations (VNA), in-home urgent care, and durable medical equipment (DME)

“The Nurse Care Managers have been instrumental in assisting the management of complex patients. Their ongoing efforts help keep patients out of the hospital, and promote communication among patients, family, and the PCP. They assist with arranging services and necessary supplies. They save hours of clinicians’ time and improve care.”

-NP, Primary Care Provider

Transitional Care (TOC) Services

Notify primary care offices of patient discharges

Obtain and review discharge documentation

Assist with follow-up calls and scheduling

Refer patients to health plans and community resources

Monitor recovery progress and intervene when improvement stalls

How Our Care Managers Support Patients and Families

Facilitate transitions from hospitals or skilled nursing facilities to home

Educate patients and caregivers on condition management and treatment plans

Connect patients with local, community-based services and supports

Coordinate medical care, including home health services and equipment

Serve as a trusted resource for patients and their families throughout their care journey

Support Our Mission

Most programs are free and we are funded by donations from the community and physicians themselves. With your generous support we can continue our mission.

Donate

The MAC Fund is a non-profit, 501(c)(3) organization.

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