Shannon Care Coordination utilizes Registered Nurses and Community Health Workers to help patients reach their healthcare goals by providing support and guidance.
Care Coordination can:
- Provide chronic disease management.
- Educate patients on their treatment plans.
- Provide motivation and accountability support for patients making behavioral and lifestyle changes.
- Help patients navigate the healthcare system.
- Facilitate communication with patients and providers.
- Identify social barriers to care.
- Offer remote monitoring for certain conditions.
- Help patients cope with emotional challenges during recovery.
Chronic Care Management Program
Shannon Care Coordination’s Chronic Care Management program is a 6-month program for Medicare patients with a physician referral and two of these conditions:
- Acute myocardial infarction
- Alzheimer’s disease
- Alzheimer’s disease and related disorders/senile dementia
- Anemia
- Asthma
- Atrial fibrillation
- Benign prostatic hyperplasia
- Cataracts
- COPD and bronchiectasis
- Chronic kidney disease
- Colorectal cancer
- Depression
- Diabetes
- Endometrial cancer
- Female or male breast cancer
- Glaucoma
- Heart failure
- Hip/pelvic fracture
- Hyperlipidemia
- Hypertension
- Hypothyroidism
- Ischemic heart disease
- Lung cancer
- Osteoporosis
- Prostate cancer
- Rheumatoid arthritis or Osteoarthritis
- Stroke or Transient ischemic attack
About Chronic Care Management:
During the initial visit (via phone), a Registered Nurse will complete a durable medical equipment (DME) assessment, reconcile all medications, and offer a home visit.
Within 24-72 hours of the initial visit, a Community Health Worker will complete a comprehensive social needs assessment and establish patient access to MyChart.
Visits continue bi-weekly via phone for up to 6 months to provide disease-specific education, comprehensive care plans and care coordination to help navigate the healthcare system.
For referrals or more information about Care Management, contact Shannon Care Coordination at (325) 747-5124.