Support clients and their families on a 24-7 basis to assist in managing difficult and urgent situations. Family members have peace-of-mind and comfort knowing that their loved one is receiving the best care possible and they are not alone.
Conduct a comprehensive home-based assessment and evaluation to devise a personalized plan of care to meet the needs of the client.
Offer guidance, education, and support to family members regarding cancer care issues and survivorship concerns.
Care Managers support each individual from diagnosis to survivorship in securing the finest in professional cancer care coordination and expert treatment planning.
Provide ongoing monitoring, individual support, social interaction, and advocacy in order to maintain the highest level of independence, quality of life, and care possible at the hospital, rehabilitation center, home residence or in a facility setting.
Supervise necessary home modifications, repair work, and maintenance in order to keep the individual's home environment safe and secure. Stage the home environment to promote healing and optimize recovery.
Utilize our expertise to navigate the maze of senior living options available from exploring: 55+ Communities, Independent Living, Senior Home Shares, Assisted Living, Small Group Homes and/or Skilled Nursing options. We will coordinate the long term placement steps, state required paperwork and assist each family in coping with the transition.
Initiate referrals to other professionals in the community for needed support services, including but no limited to: referrals to physicians and other medical professionals, mental health services, elder care attorneys, realtors, financial planners, dieticians, etc.
Provide oversight and advocacy at appointments to ensure that critical information is presented to the client's medical team, doctor's orders are properly obtained, and accurate information is relayed back to the client's family and/or responsible party.
Faithfully advocate for the individual on behalf of their family members. Apply our knowledge of state regulations and our familiarity with the structure of long term facilities for the betterment of our clients. This includes updates routinely furnished to family members and healthcare professionals.
Help determine if the individual meets the criteria for the various benefit programs available and assist with the application process. Securing benefits can help each individual pay for prescription drugs, medical care, food, or heat for their homes, to just name a few. Are you a Veteran? Let us help.
Patient Problem(s): Difficulty getting from home to destination where they obtain their health care.
1. No public transportation or it is too much of a hassle.
2. Trouble finding someone with a car who can drive them.
3. Patient doesn’t live near accessible public transportation.
4. No family/friends available who can give patient a ride.
Care Manager Solution: Coordinate Patient Transportation.
Our Care Managers make arrangements to overcome the barrier of transportation and help assist patient in getting to medical appointments by:
1. Calling an agency to arrange for a ride.
2. Helping patient to complete paperwork for transportation assistance.
3. Providing transportation to patient.
4. Giving patient means to travel, example: taxi voucher, bus tokens, etc.
Patient problem(s): Dealing with financial problems that interfere with receiving needed health care services.
1. Not being able to understand medical insurance coverage detail and knowing what costs to expect during and after diagnosis and in treatment planning.
2. Organizing finances and difficulty paying for treatment and follow-up healthcare is a problem.
3. Not understanding all available financial resources and other benefits they may qualify for, such as: Veterans benefits, (LTC) Long Term Care Insurance, Disability Insurance coverage detail, etc.
4. Confusion surrounding new medical bills and co-payments, making it hard to arrange health care.
5. Not knowing how to navigate new expenses and the costs associated with treatment(s), as related to cancer care, along the continuum of care.
Care Manager Solution: Coordinate and make arrangements to provide financial help to the patient.
1. Help patient complete paperwork for community assistance.
2. Call agencies to locate financial help and locate other helpful tools/resources.
Patient Problem(s): Worry and concern about where they live during their health care following diagnosis or where to live now due to change in physical or financial ability, due to new level of care & scope of needs.
1. Has to move to obtain care, because of new scope of care needed.
2. Moving frequently and needing a secure and stable home environment.
3. Currently living with a relative/friend.
4. Need to downsize, no longer able to function safely in environment.
5. Has safety concerns in current residence and an evaluation of both safety (inside/outside), is needed.
Care Manager Solution: Support patient in securing new living residence based upon new financial, geographical, and scope of care needed.
1. Help patient in de-cluttering, downsizing, and organizing home.
2. Coordinate necessary relocation pieces.
3. Completing state required physician paperwork for assisted living facility and other vital components.
4. Make necessary modifications and repairs to current home environment, based upon home outcomes of home safety evaluation and screen (indoor/outdoor).
5. Coordinate referrals to real estate specialists, appraisers, home repair/handy man, home movers, and other home safety services, snow removal, landscapers, etc.
6. Assist patient in locating the best professionals in the real estate and housing markets in geographical area.
7. Support patient in touring appropriate housing (in person or online via virtual tour) 55+ retirement communities, independent living, assisted living, small group homes, memory care, and/or skilled nursing care environments.
Patient Problem(s): Not understanding how to navigate and coordinate the essential pieces of cancer care and treatment planning following an often overwhelming and unexpected cancer diagnosis along the continuum of care.
1. Trouble navigating the complex health care system on their own accord (hospital & clinical settings).
2. Not understanding each entity and the different function of underlying administrative systems and processes involved with each organization.
3. Not knowing what essential care coordination pieces are needed after diagnosis is confirmed, in treatment planning, post treatment, and in survivorship planning.
4. Not knowing who to turn to and trust with their healthcare needs and what “vetted” professionals to reach out to in the local community, as well as not being aware of what organizations they can turn to, during an overwhelming time.
5. Not understanding what questions to ask each professional and provider, in order to thoroughly “vet” them.
Care Manager Solution: Help the patient navigate and coordinate all essential pieces of cancer care as related to diagnosis, treatment, and survivorship planning post by lining up the right people, places, opportunities, and other necessary components needed according to the patients identified needs.
1. Tour and establish meetings with potential healthcare providers and other medical professionals to identify whom the patient would like to work with as part of their elected cancer care team.
2. Vet each professional to the best of our ability and address all patient apprehension and/or concerns.
3. Coordinate professional referrals and connect patient to the best medical and non-medical person(s) and entities, available in the community they reside.
4. Provide patient with information on community agencies that may be able to help (brochure/business card/flyer) for the patient to call themselves, when requested.
5. Give the patient a list of community agencies for the patient to call themselves, when requested.
6. Follow up with each provider and/or clinics in advance based upon patient need(s), to reduce communication problems and ensure patient has best care experience possible.
7. Work with the social worker on behalf of the patient when needed and coordinate essential pieces of care for patient.
8. Speak with the provider about recommended cancer care needed for patient and advocate in advance to ensure that the provider can meet needs and exceed basic patient expectations.
Attitude & Perceptions Towards Providers:
Patient Problem: Perceptions and beliefs about the health care providers negatively impact receiving necessary care.
1. Lack of trust in the healthcare system.
2. Resistant due to poor experience in past with health care team regarding themselves personally or with family.
3. Community’s negative beliefs about health care system.
4. Patients own personal values and belief system whether cultural, religious or other.
5. Felt disrespected/treated rudely by staff in past.
6. Doesn’t believe what doctors say.
Care Manager Solution:
1. Keep the information simple for the patient as in health care there is common usage of various jargon and acronyms.
2. Give patient access to their medical records to participate in and review care recommendations, making patient equal partner in their health care decisions.
3. Be as specific as possible regarding communications with all patient concerns.
4. Get patient involved in setting their health care goals and be proactive and not reactive.
5. Ensure that patient and medical team are both on the same page via communications, act as liaison.
6. Make information sharable to individual patient and their support network.
7. Create accountability.
8. Openly discuss each area of concern and hesitancy in patient concerns to overcome barriers.
Patient Education & Understanding:
Patient Problem(s): Difficulty understanding their diagnosis and what it means to them regarding the suggested course of action per clinical team and the importance behind the care plan detail offered.
Care Manager Solution: Explaining something to the patient that is related to the patient’s health condition, in an understanding and supportive manner.
1. Review a brochure with the patient.
2. Showing the patient a model or poster of health problem or anatomy.
3. Going through website information with the patient.
4. Conduct research on the computer for the benefit of the patient and pull needed health related care and information.
5. When possible, check medical record and other online systems such as test results, appointments, and referrals are in place.
Patient in Fear:
Patient Problem: Fear about any aspect of medical care or their health.
1. Patient states that they are fearful about dying.
2. Patient does not know how to tell family and friends and is fearful of sharing diagnosis.
3. Patient family fearful.
4. Patient states that they are scared about getting the test done, that test will hurt.
5. Fear of unknown/doesn’t want to know results
6. Fear of treatment.
7. Fear of doctors/nurses or hospitals/clinics.
8. Fear of telling employer and losing their job/termination/benefits.
Care Manager Solution: The Care Manager can assess for anxiety while completing the initial evaluation or by using an anxiety (distress) scale similar to a pain scale to know the signs and be able to recognize anxiety.
1. Talk to the patient and establish open communication to build trust.
2. Actively Listen to patient concern(s).
3. Offer empathy.
4. Help patients relax via relaxation techniques.
Patient Problem: Patient has a disability which makes getting healthcare difficult
1. Visual or hearing problems.
3. Wheelchair or Walker.
Care Manager Solution(s):
Provide complete assistance for patient who may need basic needs met due to disability such as shelter, rent, food, and medications
1. Assess patient for abuse or risk for abuse (physical, emotional, financial, and sexual) by others (family, paid care providers, strangers).
2. Assess what accommodations the patient has made at home or needs at home to encourage or permit self-care and independence. Identify accommodations needed during hospital stay or when out of the home.
3.. Encourage patient in activities and areas that they can control by assessing patient’s awareness of accessible community-based facilities [e.g., health care facilities, imaging centers, public exercise settings, transportation] to enable them to participate in health promotion.)
4.. Provide accommodations and alternative formats of instructional materials (large print, Braille, visual materials, audiotapes, interpreter) if needed by the patient with a disability.
5. Determine if patient instruction materials are consistent with modifications [example, use of assistive devices] needed by the patient with disabilities to enable him or her to adhere to recommendations.
6. Determine if the modifications made in educational strategies address learning needs, cognitive changes, and communication impairment of patient, if needed.
7. Assess the patient for depression or any secondary risk conditions.
8. Assess patient's ability to communicate and participate in health history and physical assessment.
9. Identify accommodations and modifications (signing, large print, etc.) needed by person with a disability to participate in their health history and assessment.
10. Assess the effect of a patient’s disability on his/her ability to obtain current health care.
11. Find commonalities that the patient can relate to, regardless of disability.
12. Ensure patient with disability is not victimized and never assume that patient views their disability as a tragedy.
13. Identify disability by using the patient’s own voice and seek to understand the person and his or her disability by conversing with the patient and involving the family members in open discussions.
14. If needed, allow patient extra time to complete tasks as related to their overall health care objectives and goals.
Out of town/country:
Patient Problem: Patient known to be out of area during their care.
Care Manager Solution(s): Contact the local U.S. Embassy (or your embassy if you are not from the United States) and receive assistance for patient in selecting a local facility if they are having difficulty finding an appropriate hospital.
1. Connect patients health insurance provider and inform them about what is happening, as some providers limit coverage if they are not promptly notified.
2. Contact patients place of work and inform them of the change in your plans and a possible change in patient return to work date.
3. Obtain medical records from patient as quickly as possible if they contain information that will be helpful for the treatment of patient’s current illness.
4. If patient has travel insurance, notify the insurance company and ensure that they are aware of patient need to potentially use coverage detail.
5. If needed, locate translators at facility to assist in patient care and inquire about potential translation services.
Patient Problem: Not having the childcare needed for necessary medical and non-medical appointments (follow up appointments, surgery, chemotherapy, radiation therapy, etc.)
1. Can’t locate a babysitter for child/children.
2. Unsure of what type of childcare to utilize according to current and changing needs due to diagnosis.
3. Budgetary concerns and difficulty in exploring available childcare options.
Care Manager Solution(s): Assess child care needs of patient and identify all potential child care options available to help assist family in obtaining the best child care possible.
1. Assess exact child care needs and overall goals as part of the planning process post diagnosis.
2. Include child care needs as related to the client’s employment and treatment schedule.
3. Continue to work with parents to address child care challenges that may arise over time.
4. Help parents secure information about available child care options and resources and refer parents to providers in direct community.
5. Screen for eligibility and refer families to public child care subsidies (if needed) and coordinate other assistance.
6. Explore cooperative approaches.
7. Work to address the particular challenges of securing care during non-traditional hours.
Location of Healthcare Facility:
Patient Problem: Distance from home residence to healthcare facility a barrier even with transportation.
1. Patient feels that the care is too far to walk or would have to use freeway.
2. Geographic barrier(s); rural living.
Care Manager Solution(s): Help patient leverage Tele-health and Tele-medicine to overcome geographical barriers, as both services offers a technological bridge to connect patients and their clinicians, no matter the distance between the two parties.
1. Use mobile clinics to go to the patient whenever possible.
2. Work with other associated networks to coordinate rides.
3. Locate other people in patients health care system and key organizations, who will work to improve transportation services in patients area.
4. Contract with transportation services.
5. Hire personal drivers for patients.
6.. Provide tele-mental health services in mental health care (e.g., psychotherapy or counseling) via telephone or videoconference for patient.
7. Provide educational and behavioral health care interventions that support patients ability to actively manage their condition(s) in every day life.
8. Coordinate rural transportation systems volunteer(s) and ride sharing.
9. Help assist patient with improved access to care through provider engagement and support.
Perceptions/Beliefs about Tests/Treatments:
Patient Problem: Patient is concerned about personal or cultural beliefs that effect receiving care.
1. Modesty (getting undressed, touched by medical staff, etc.)
2. Belief the test or treatment is harmful and will make things worse.
3. Puts trust in higher power as reason for not completing recommended care.
4. Perception that there is nothing wrong.
5. Results don’t matter; put trust in higher being .
6. Doesn’t believe treatment will help.
7. Embarrassed to tell friends/family.
Care Manager Solution(s): Help patient to overcome cultural barriers and embrace cultural differences by being culturally sensitive and ensuring effective cross-cultural communications are in place by ensuring cultural awareness, knowledge, and communications are supported between patient and their provider(s).
1. Ensure clear and polite communication.
2. Learn about the patients culture and what is most important to them during the assessment process.
3. Be proactive and work towards accommodating patients cultural differences into the care plan.
4. Share knowledge and understanding of patients cultural beliefs with clinical team.
5. Employ diversity training, as needed with each provider per the patients personal and cultural beliefs regarding care received.
Patient Problem: Social support network is not available (person/community) to help patient through the care needed following the diagnosis.
1. No person/family/friend/neighbors/church to help patient through care.
2. Distance and geographic location (isolation) from other family members or support system who could help.
3. Complicated family dynamics or a particular situation that is out of patient control.
4. Family member (Power Of Attorney) makes all healthcare decisions for patient and not the patient themselves.
Care Manager Solution: Provide support the patient to improve the person’s emotional and social situation.
1. Attend and accompany patient regarding medical and non-medical related appointments, as needed.
2. Meet and support the patient at medical appointment, in clinical setting, or at the home residence.
3. Wait in the waiting room or attend part of the medical appointment or all of the appointment with the patient (a medical appointment includes surgery, radiology, laboratory, infusion center, physical therapy, etc.)
4. Support the patient in meeting with the social worker, community agency, psychologist, cancer resource center, etc.
Coordination of Insurance and Paying for Care:
Patient Problem: Complexity in understanding how to navigate the insurance path and difficulty in understanding coordination of the various insurance pieces and in paying for care
1. Medication not covered even though insurance is in place.
2. No current health insurance.
3. Can’t afford the high co-pay/deductible.
4. Can’t afford the medications.
5. Discount offered/payment plan isn’t enough.
6. Doesn’t want to receive the bills/bills are a stressor.
7. Overwhelmed by insurance paperwork.
8. Doesn’t understand what insurance covers as related to the diagnosis and care plan detail outlined per medical team.
Care Manager Solution: Working with others to help the patient obtain a plan and/or an available program, to assist in managing the cost(s) associated with all aspects of patient related cancer care.
1. Arrange for the patient to have an appointment with the enrollment specialist.
2. Helping the patient obtain the forms for insurance or Medicare/Medicaid.
3. Working with insurance (private or Medicaid/Medicare) to obtain preauthorization’s, and referrals for the patient.
4. Working with registration staff to ensure the patient is not receiving bills.
5. Working with staff to ensure that the patient is on the appropriate program.
Patient Problem: Difficulty finding support and oversight for other family members when patient needs medical care
1. Couldn’t find someone to care for elderly patent with Memory Loss/Alzheimer’s.
2. Could not leave spouse/ other family member to go to appointment.
Care Manager Solution: Overcome barriers and create a plan of action by providing possible care solutions to family caregiver post assessment, so patient may successfully attend and schedule necessary medical appointments, as needed.
1. Locate adult day care program in community.
2. Help patient as primary caregiver, coordinate and formulate a schedule with focus on grouping multiple medical appointments together, to ensure best use of time management.
3.. Secure non medical home care oversight (private caregiver).
4. Look into patient support network and coordinate care options available between community partners, friends and neighbors of caregiver.
Patient Problem: Lack of social support network available to individual (family, friends, and other community members) for various reasons, resulting in patient feeling alone and overwhelmed emotionally after diagnosis is confirmed and along the continuum of care post.
Care Manager Solution: Provide direct support to patient to improve the person’s emotional needs and help patient connect and expand their social network, as needed.
1. Provide encouragement and empathy to the individual.
2. Making other necessary arrangements to provide assistance that is not transportation or financial related.
3. Listen to the patient and allow them to openly express their emotions.
4. Spend time with the patient so that they do not feel alone.
5. Help the patient by connecting them to other individuals in similar situations via related support groups (online or in-person).
6. Help encourage social interaction by activity and connection in the local community, whenever possible.
7. Help assist with referrals to appropriate mental health professionals and with other helpful interventions for patient, as needed.
Communications: Family & Support Network
Patient Problem: Unable to communicate effectively, all the various and crucial pieces of their cancer care journey on their own accord, to their family and support network.
1. Communication breakdown between patients and members of patients main support system.
2. Information overload and not understanding most relevant clinical care pieces.
Care Manager Solution: Meeting and speaking with the patients support network to discuss all arrangements and ways to effectively help the patient.
1. Talk to supportive people to meet the needs of the patient.
2. Coordinate between all the parties involved, what the support members will do and what the (Care Manager) will do; defining roles between all members, pin-pointing support(s) needed and assignment/delegation of those tasks as related to the individual patient and desired outcomes.
Scheduling of Appointments:
Patient Problem: Unable to successfully manage, set, make and navigate the suggested timeline and medical/non-medical appointments on their own accord or due to employment restrictions.
1. Didn’t understand instructions by the receptionist or medical professional about the next appointment and the reasons for the various appointments (medical/non-medical in nature).
2. Work related scheduling conflicts which make getting health care difficult.
3. No sick time available—therefore loses pay.
4. Worried will lose job.
5. Too busy to leave work for appointment.
6. Can’t tell boss/supervisor what is going on (fear or embarrassment).
Care Manager Solution: Involvement in the scheduling of the patient needs, per all necessary appointments and/or follow-up care meetings.
1. Call or help the patient call the appointment scheduling line.
2. Send an email or call a provider/clinic to ask for appointment(s) for patient.
3. Ensure timely appointments are made for individual along the continuum of care.
4. Appointment reminder; call patient to remind patient of upcoming appointment and ensure readiness.
5. Contact patient by telephone, mail, or email to remind patient of upcoming appointment(s).
6. Create a plan for patient regarding his/her employer.
7. Review the patients company policy per situation and assist patient, as needed.
8. Support patient in accessing work related benefit information.
9. Help patient if needed, with necessary work related accommodation’s and outline necessary steps.
Medical and mental health co-morbidity (health problem that co-exists with the screening abnormality):
Patient Problem: Patient may have other medical health problems he/she is also managing, or mental health problems (not assessed by the Care Manager) that make getting health care difficult.
1. Have bad arthritis.
2. Bad diabetes or heart failure.
3. Patient tells you that they are severely depressed.
4. Patient known to have substance abuse problems.
5. Patient known to have alcoholism.
6. Patient has multiple health problems (Example: diabetes, arthritis, COPD, and cancer).
7. Patient doesn’t feel well enough to get test/results/treatment).
8. Feeling too stressed out.
9. Couldn’t motivate self.
10. Patient has mental health condition.
Care Manager Solution: Assessments used to pin-point and identify exact patient needs and refer to appropriate medical and non-medical professionals.
Communications & Various Health Care Partners & Medical Personnel: Patient Problem: Communication concerns with various personnel and having trouble in understanding all the clinical information given.
1. Didn’t understand instructions by the receptionist about next appointment.
2. Didn’t understand physicians’ instruction about what the tests were about.
3. Doesn’t understand cancer or what their diagnosis means.
4. Unaware of importance of making necessary medical appointment(s).
5. Didn’t understand what they were asked to do according to care/treatment plan.
6. Medical forms to complicated to understand thoroughly.
7. Patients doesn’t feel comfortable speaking English as it is not their first language.
8. Clinical staff does not speak native language of patient.
9. Literacy and difficulty in understanding written information from the health care setting (can’t read/illiterate).
10. Has difficulty reading- low literacy/learning ability.
11. Information overload and not understanding relevant pieces of information from clinician and various team members.
Care Manager Solution: Interact with healthcare team upon patient’s behalf and help patient overcome barriers to understanding the information given by medical team.
1. Speak to doctors, nurses and other providers in healthcare to enhance and assist patient regarding communications.
2. Discuss with the patient the upcoming medical visits, proposed tests and treatment that will be needed for patient and ensure understanding and comprehension.
3. Locate an Interpreter, if needed, to assist in clear and precise communications with patient.
System Problems with Scheduling Care:
Patient Problem: Care provided to patient is not convenient/ efficient to patient’s needs.
1. Put on hold too long to make appointment.
2. Had to wait too long and had to leave before appointment.
3. Office hours not convenient.
4. Appointment needed not available, too far into future.
5. Doesn’t have own telephone/phone or unable to use at. present time.
6. Called to make appointment, but wasn’t able (put on hold, busy, no answer).
7. Called to make appointment; appointment date/time wasn’t convenient.
8. Called to make appointment; appointment date/time given was far in future.
9. Clinic isn’t open when it’s convenient.
10. Mail is only way can be reached.
Care Manager Solution: Help patient by ensuring medical office systems are streamlined (patient flow) via communications to improve appointment scheduling and appointment access.
Coordinating Other Assistance for Patient:
Patient Problem: Difficulty in making arrangements to provide assistance that is not transportation related or financial in nature.
Care Manager Solution: Complete thorough screens that will include a formal assessment, in order to pin-point areas of strength and of need resulting in positive clinical outcomes. The goal is to minimize patient problems to further reduce any barriers present along continuum of care into survivorship.
No matter what you may need assistance with today, our team of professionals are here to help support you along your care journey!
10940 S Parker Rd. # 522, Parker, Colorado 80134, U.S.A.
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empowered for your journey!