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Care Continuum

Our Nurse Care Managers utilize a Nurse Health Care Continuum 
care management model to provide individualized, quality health care management
for our clients.
Need Assessment, Care Planning and Communication
The Nurse Health Care Continuum® model has three stages:

1. Initial Assessment & Care Recommendations

Our Nurse Care Manager conducts an Initial Assessment to identify current and potential issues that impact well-being. This interview covers all topics that pertain to a client’s total health, including physical and psychosocial well-being, medication adherence and side effects, and environmental safety. Once our client’s needs have been established, RN Health Management develops recommendations to promote the client’s health and safety in their daily lives.

2. Plan of Care and Implementation

The Plan of Care is designed to outline our client’s personal health priorities.  We develop an individualized Plan of Care based on the issues identified during the Needs Assessment. This Plan of Care provides direction for the multidisciplinary care team’s actions and goals to promote the best possible care and outcomes. The Plan of Care implementation involves an array of care management activities through which the plan is put into effect.

3. Reassessment and Communication

Based on the personalized needs of the client, reassessment visits are scheduled weekly, bi-weekly, or monthly.  During these appointments, our Nurse Care Manager reassesses the client, updates the Plan of Care, and communicates with the multidisciplinary care team.  This reassessment and communication process ensures that all members of our client’s care team – including family, physicians, and caregivers – are aware and focused on the client’s current health and safety.

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