What is RN Care Management?

RN Health Nurse Care Manager

- Introduction Video

Hello, my name is Lee-Anne Godfrey, and I am the founder and president of RN Health Management. 


RN Health Management consists of a professional team of Registered Nurses who provide comprehensive services to the older adult, wherever they are on the health continuum. 


These services include advocacy, healthcare navigation, and monitoring as well as oversight of care.


We work with clients and families, bringing together a comprehensive care management team who are experts in managing and navigating health care and aging issues in a holistic way. 


As well as focusing on clinical concerns, we address the promotion of health and the prevention of illness and other undesirable outcomes such as hospitalization.


Our client’s safety, health, and well-being are our top priorities. 


Unlike home health nursing, we do not provide direct, hands-on nursing care. 


Rather we coordinate and manage the care our client needs.  Perhaps it is accessing covered Home health benefits with therapists coming to the home to develop a personalized therapy plan that can be followed in the home.  


Maybe it is coordinating a dietician to visit the client who has just been diagnosed with diabetes and then working with the caregivers to create nutritionally appropriate meals.


In all that we do, we focus on communication, collaboration, and coordination with all members of the care team. 

Members of the care team include our client, family members, physicians, caregivers, therapists, and community resources, and programs.


So what are some examples of what RN Health Management does for our clients? 


Let’s start with Healthcare Navigation and Coordination. 


We help navigate the healthcare system, its various components, and options. 

As we age, we see more and more healthcare providers.  The system works best when we thoughtfully navigate through the system, anticipating next steps. 


We communicate with the providers, so everyone is on the same page and services are utilized properly and in a timely manner.  We coordinate visits to the appropriate providers at the right time.

Transitional Support: Whether it’s preparing to leave the hospital or a rehabilitative program, moving to an assisted living community, managing a new diagnosis, or initiating palliative care, we are here to help with those care transitions.


This support can entail ensuring referrals are in place for follow-up services such as physical therapy or follow-up appointments with specialists.


This may involve obtaining durable medical equipment (e.g. wheelchair, shower chair or a lift) or educating caregivers on changing care needs to provide a safe transition back home.

Medical Appointments:  Keeping track of multiple medical appointments and scheduling new ones can be challenging. 

We help coordinate appointments to ensure timely and appropriate care. 


When needed and desired, we accompany our clients to medical appointments.  This helps the healthcare provider fully address questions and concerns, and we can help our clients understand results and options. 


Follow-up visit reports can be provided to designated family members. 

Medication Management:  Medications and their proper management can be confusing.   Our registered nurses help our clients plan for when and how to take their medications.  We work with our clients to create a Medication Administration Record (MAR) tailored to their needs.  This organization helps ensure medications are taken accurately and safely while also being able to monitor for potential side effects and interactions. 

We also provide education and support to caregivers who are often in the role of assisting our client with their medications.

Caregiver Training:  Caregivers are a critical part of the team and are essential to the well-being of our clients. 

Our registered nurses work with caregivers and their associated company to provide caregiver training for that specific client.

Client specific caregiver training supports our the older adult in receiving the most effective and personalized care according to their clinical status, needs, and wishes. 

Caregivers often need ongoing training for changes in client condition, such as an acute illness or a decline in function for example.

Family Communication: Between work, family obligations, or distance, staying current on a loved one’s condition and associated needs is challenging.

We regularly communicate with designated loved ones so that they remain involved and informed about the details.   

Crisis Management: Crises can come in many forms – a fall, a hospitalization, or an unexpected diagnosis.   

Whatever the crisis, our clinically experienced and licensed staff support our clients and families through the crisis and help them to adjust to new needs and conditions. 


Our goal is to anticipate needs and avoid crises whenever possible.

These are just a few examples of the support RN Health Management can provide to clients and loved ones. 

How do we know where to start and how to tailor all of these services for our client?

We start with an in-depth assessment to identify the unique current and potential issues that impact the well-being of that individual client. 

We collaborate with the client, loved ones, and others on the care team, such as physicians, to develop a personalized plan of care.  We talk about the needs, goals, and abilities and set priorities together. 

This comprehensive assessment reviews health and wellbeing in a holistic and proactive manner.  It includes physical, psychosocial and emotional considerations as well as important practical concerns such as medication management and environmental safety.

This assessment allows us to identify and prioritize issues of concern and then tailor client-specific solutions to prevent, manage and resolve problems and promote health.  Once the goals of care have been established, the RNHM nurse works with the client, loved ones and other care providers, such as physicians, to consider options and develop recommendations. 

Such a holistic plan of care promotes health, safety and maximal well-being.  Of course, the plan of care is constantly evolving but always serves as a road map, providing direction for our client and their team of care providers. 

Utilizing licensed professionals such a Registered Nurses specialized in aging in place provides clients and families the peace of mind that the many intricate details of care are being overseen and managed.


At RNHM we see each client as an individual with unique needs, desires, and abilities.  Our role as Professional Nurse Care Managers is to oversee, support, and empower our clients wherever they are on the healthcare continuum. 


Communication, collaboration, and coordination are essential to what we do and forms the basis of our care.


For more information or to schedule a consultation, please contact us. 

We look forward to serving you and your loved ones.