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Nurse Case Manager 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 the navigation through the health care system and continuous improvement of patient outcomes and nursing care.

Benefits of Nurse Case Manager / Services Provided

  • Healthcare resource for the staff
    • Assist with health management problem solving of difficult cases
    • Staff education on nursing management of long term care residents to improve quality of care
    • Mentoring and education of staff to develop evidence-based practices
  • Assessment and evaluation for appropriate level of care and needs
    • Liaison between residents, families and facility staff
    • Evaluate resident pre and/or post admission
  • Health Care Resource for residence and family
    • Health promotion and maintenance and prevention of complications
    • Answer questions, follow up and follow through with medical management and health concerns
    • Health education for residents and family for improved compliance and understanding of current health management
  • Identify specific care problems, then develop & implement an intervention program for example
    • Develop bowel and bladder program for management and prevention of complications
    • Documentation and interventions for non-pharmacological management of behavior in dementia residents
  • Assistance with management of medical problems and health concerns
    • Evaluation of health status of residents
      • Recommendations and assistance with medical decision making
      • Assist with finding appropriate services in-house or in the community
      • Responsible for disease management in coordination with the primary care provider & nurse practitioner
    • 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, etc.)
    • Collaborate & work in conjunction with other health care providers for appropriate orders and medical management following CMS guidelines
      • Early identification and treatment to potentially avoid hospitalization
      • Recommendation for evaluation or orders, e.g. physical therapy, medications, etc.
      • Participate in resident care conferences

Request more information

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

Paragon Clinical, LLC.