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Nurse Case Management Program

The nurse case manager is a practice-based nurse who collaborates with other members of the health care team to assist the facility in providing high level, quality care. The nurse case manager is responsible for providing care coordination and care management services to residents who are at risk for health deterioration, change in condition and poor outcomes. The goal of this program is to assist residents, families and staff with navigation through the health care system and continuous improvement of patient outcomes and nursing care.

Benefits of Nurse Case Manager / Services Provided

  • Health Care Resource & Advocate for residents
    • Health promotion, maintenance and prevention of complications
    • Answer questions, follow up, follow-through with medical management and health concerns
    • Health education for improved compliance and understanding of the current health management
  • Assessment and evaluation for appropriate level of care and needs
    • Liaison between residents, families and facility staff
    • Evaluate resident pre and/or post admission as needed
  • Healthcare resource for the staff
    • Assist with health management problem solving of difficult resident cases for management & prevention of complications
    • Assist with recommendations for non-pharmacological management of residents with difficult behavior
  • Assistance residents with management of medical problems and health concerns
    • Evaluation of health status of residents
      • Recommendations and assistance with medical decision making in coordination with the primary care provider &/or nurse practitioner.
      • Assist with finding appropriate services in-house or in the community
      • Early identification and treatment to potentially avoid hospitalization
      • Recommendations for evaluation or orders, e.g. physical therapy, medications, etc.
      • Participate in resident care conferences
    • Provide suggestions for management & maintenance of:
      • Mobility and activity
      • Bladder & bowel health
      • Mental health issues
      • Medical conditions (e.g. diabetes, hypertension, arthritis, pain, etc.)
      • Health promotion
    • Efficiency of medical / health care utilization
      • Decrease hospitalizations / emergency room visits for potentially avoidable reasons
      • Evaluation of utilization of available health care resources (in-house staff, therapy, outside health care providers, etc.)
      • Early identification and treatment to potentially avoid hospitalization
      • Recommendation for evaluation or orders, e.g. physical therapy, medications, etc.
      • Participate in care conferences, if possible

Request more information

For more information about Paragon’s Nurse Case Management Program contact Dr. Mary Beth Sutkowski at mbsutkowski@paragonclin.com.

Paragon Clinical, LLC.