Care Coordination

ServicesCare Coordination

Legacy Protection Planning’s Teamwork approach to Care Coordination

We align our services with care managers, home care agencies, and others to ensure the continuum of care among providers. This approach eliminates duplication and reduces the cost and stress of long term care.

Examples of specific care coordination activities include:

  • Coordination and collaboration with care manager, home health workers, and other providers
  • Establishing accountability and agreeing on responsibility
  • Communicating/sharing knowledge
  • Helping with transitions of care
  • Assisting the Care Manager in executing the clients Care Plan
  • Supporting client’s self-management goals
  • Linking community resources
  • Track and support clients when they obtain services outside their primary care practice like Emergency Departments, Hospitals, Rehabs and other health care facilities
  • Follow-up with client within 24 hours of an emergency room visit or hospital discharge
  • Under the direction of the practitioners, communicate test results and care plans to client/families
  • Provide relevant self-management support for clients with chronic illnesses as identified by clinical teams
  • Assist clients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance)
  • Collaborate with other members of home care services and care management activities including implementation of Care Plan
  • Manage referrals, when needed, to appropriate agencies required to assist the client in achieving the goals and objectives identified in their Care Plan

 

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