CARE CLINICIANS
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A Care Clinician is a licensed, trained, and experienced nurse or social worker who coordinates between the patient and providers to prevent health complications from illness and improve overall well-being.
What is a Care Clinician?
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A Care Clinician provides the best complex care management to patients; the frail, elderly, chronically ill, and/or functionally challenged. The goal is to help each patient live their best life in a safe home environment and prevent hospitalizations through education and support.
What does a Care Clinician do?
Care Clinician Services
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Educate post-hospital patients on discharge instructions, medication reconciliation, follow up appointments, and any resources to help the patient transition successfully from the hospital setting back to their home environment.
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Conduct an assessment and work with the patient to develop an individualized care plan. The assessment may include obtaining medical and family history, asking about current level of physical ability, cognitive awareness, emotional status, determining patients environmental safety at home, and discussing any financial or legal end of life issues.
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Provide education on chronic disease processes to prevent hospitalizations.
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Ensure coordination of care between the patients, their physicians, their home care team including home health services and their appointed family members.
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Act as an advocate for patients.
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Provide crisis intervention as needed.
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Help the patient obtain outside resources to improve their quality of life including finding someone to assist with ramps or grab bars, helping to locate assistance with medication costs or utilities, ensuring patient has transportation to and from doctor visits, showing the patient where to apply for food stamps if needed, etc.