Create healthier communities by partnering with local establishments and providing them with a toolkit needed to help residents manage their chronic illnesses.
Refer to continual educational classes provided by Atrium Health Navicent, such as Smart from the Heart and Tobacco Cessation Program.
Chronic Care Management
Provide person-centered care in the community to patients who are in the later stages of their diseases.
Promote healthy lifestyle changes with disease management training and preventative care.
Reduce health barriers by connecting patients to appropriate agencies and resources, such as meals on wheels, Area Agency on Aging, the food bank, First Choice Primary Care and others.
Advance Illness Management
Case Managers are providing services to patients in need of more intense case management outside of the hospital, by completing an extensive comprehensive assessment to determine the needs of the patient.
Determine motivation of the patient through Motivational Interviewing, and identifying patients' support systems.
Provide prognostication awareness and promote self-management.
Facilitate goals of care and quality of life discussion, encourage advance care planning.