Medical Home Visits: After the Physician Team Leaves
Cindy Hasz, Director
Grace Care Management
November 10, 2004
Physician Team to Care Manager

Referral from Physician Team to Community Care Team
Assessment, ID needs, Care plan, care coordination, on-going reassessment
Multidisciplinary team
Feedback system

Chronic Care Management:
Proactive: stabilize at home
Prevents acute care use & $$
Based on Quality of Life: dignity, choice
Need for recognition of value by Public funding sources
Private sources: LTC insurance, families, private pay
Improved outcomes

Mr. Z
92 yo, lives alone, only son out of state
HTN, dementia, risk for undue influence
APS referral, has assets, at risk for self-neglect
Cognitively unable to follow treatment plan
Needed assist w/ADLs and IADLs
Placement vs. home care?

Mr. Z today
In-home care carries out tx plan
Controlled HTN, adequate nutrition, safety, Gracie , companionship
Cost is $60/day or $2000/month
Mr. Z is happy and healthy at home!

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