For members who need services that can only be delivered within a healthcare setting, the coach will identify qualified facilities based on the member’s treatment needs. The coach will ensure that the transition from one setting to another occurs smoothly and that the receiving facility is prepared to meet the member’s needs.

Once a member can be cared for at home, the health coach will work one-on-one with the member and the family to create an individualized care plan. The care plan helps the member, providers, caregivers and coach collaborate to optimize the member’s recovery, avoiding unnecessary complications that prolong treatment or require readmission to a hospital. A care plan includes benchmark goals and is updated to reflect the member’s progress. This process increases members’ confidence in their ability to manage their recovery and encourages them to learn new behaviors to achieve better health.

The care plan is created by assessing current health risks, acute deficits in the member’s mental and physical level of function, any environmental risks to safety, the capacity of the member and family to provide monitoring and self-care, and the member’s current motivation to participate in the plan.

To manage the member’s acute risks, the plan will identify additional private or community service providers and transportation to outpatient service locations, as necessary. Specific attention will be paid to the needs of the family and other caregivers, as the emotional and financial burden associated with care-giving can disrupt otherwise positive relationships. With knowledge and personal support, members and their families use the care plan to be active participants in managing the member’s health and communicate with healthcare providers.

Carewise Case Management coaches are registered nurses with expertise in relevant clinical areas. Our RN health coaches have an average of 15 years experience and are required to receive continuing education credits to ensure their knowledge is current.

The nurses are supported by a full-time, on-site staff of medical directors who are available for consultations on complex cases and provide routine case reviews. They also conduct professional development programs for staff on topics that arise from case reviews.

You will never have to wonder if your program is successful. Our method of measuring outcomes with precision is unmatched in the industry, and we provide reports that a lay person finds easy to read. You will clearly see whether there are demonstrated reductions in hospitalizations, emergency room visits and hospital readmissions – as well as the corresponding cost savings. In this way, the effectiveness of your program is validated, and you can refine your strategy over time as the risk profile of your population changes.

Our goal is to achieve the best possible clinical outcome for each member while yielding cost savings – the only path to truly sustainable savings over time.