At Northside, we CARE …
Welcome to a new era in health care … Chronic Care Management.
Through our dedicated CARE Team, we deliver:
- Services for patients with multiple (2 or more) chronic conditions expected to last at least 12 months or until the death of the patient. The chronic conditions suffered by these individuals may often place the patient at significant risk of death, acute decompensation or functional decline.
- An oversight and education tool for the patient to ensure that they understand and manage their condition and live with it successfully to ensure an ongoing quality of life.
- Better health and care for individuals.
With our CARE Team, you benefit from:
- Use of a Certified Electronic Medical Record (EHR)-Patient Portal
- Demographics, Problems, Medications, Medication Allergies
- Continuity of Care with Designated Care Team Member
- Comprehensive Care Management and Care Planning
- Transitional Care Management
- Coordination with Home and Community Based Clinical Service Providers
- 24/7 Access to Address Urgent Needs
- Enhanced Communication (Email, Monthly Phone Calls)
- Advance Consent
- Verbal Consent from patient documented in Medical Record
Who is eligible for CARE?
- Medicare Patients
- Patients with repeat Hospital and/or Emergency Admissions
- Must have 2 Chronic Conditions such as:
- Alzheimer’s disease or related dementia
- Arthritis (Osteoarthritis and Rheumatoid)
- Atrial Fibrillation
- Autism Spectrum Disorders
- Cardiovascular Disease/Congestive Heart Failure (CHF)
- Chronic Kidney Disease (CKD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Infectious Diseases such as HIV/AIDS
Who else is eligible?
- Homebound Patients unable to drive
- Fragile, Elderly patients at high risk for hospital readmission
- Transition Care Management (TCM) patients
- Quad, Paraplegic patients
- Patients with Chronic and progressive neurological diseases such as ALS, Parkinson’s, Advanced MS, Dementia
- Mentally Ill Patients
- Patients with social barriers such as caregiver help, transportation needs, Medication Assistance, Food Social Isolation
What does CARE include?
- Care Coordination
- Transitional Care Management
- Home Visits
What are the benefits to me?
- Structured recording of patient health information
- Care Coordination Patients can still have in office/face to face visits.
- Care Coordination serves as in between visit care management.
- Continuous relationship with a designated member of the care team
- 24/7 access to care support and health information
- Preventive care
- Patient/Caregiver engagement
- Patient support by care team member to achieve health goals
- Timely sharing of health information between providers
- Home visits to help patients achieve health care goals, assess needs, perform preventive care, take vital signs and obtain necessary lab work
How much does it cost?
- $8.00 per month for Medicare patients
- Financial assistance is available
What else does CARE plan to do?
- Involve local church and other community groups to provide patient social interactions.
- Provide weekly/monthly social events on campus to involve C.A.R.E program members
- Obtain Northside owned Transportation services to assist with patient transportation issues
- Establish a Not for Profit program and obtain grants to assist with C.A.R.E program members financial needs
- Work with City and County leaders to support and fund C.A.R.E. program.