SOCIAL WORK
CARE COORDINATION
MANAGED CARE CASE MANAGER
Kristy Blaisdell, RN
[email protected]
Fax # 617-259-2199
HOW WE CAN HELP
We offer crisis intervention, guidance, support and referrals. We meet with patients and their families at the practice, talk with them by phone, or meet in their home if appropriate. We can help make a plan to find the right solutions.
Some of the things we can help with:
We offer crisis intervention, guidance, support and referrals. We meet with patients and their families at the practice, talk with them by phone, or meet in their home if appropriate. We can help make a plan to find the right solutions.
Some of the things we can help with:
- Financial stress and needing to find State and other assistance programs
- Medical insurance and prescription drug assistance referrals for information
- Home care through Elder Services (low income) or private home care agencies (home health aide, housework) companionship etc
- Reducing isolation/loneliness through community programs at senior centers or support groups
- Health coaching referral for better disease management
- Transportation programs (PT-1/MassHealth; Town medical vans; MBTA The Ride)
- Assisted Living referral service for education guidance about options
- Home Safety assistive devices: Lifeline, Medication Dispenser, Medicaid cell phone
- Family/Elder Law attorneys for estate and long term care planning
- Housing specialist agencies for prevention of homelessness and subsidized housing applications
- Caregiver support and guidance/referrals
- Therapy/counseling referrals to help with anxiety, depression and chronic illness
- Food assistance programs
- End of life planning and support
Social workers provide social work case management services. They works to address the unmet psychosocial needs of patients, which have a high impact on disease management. They provide BMA clinicians with a fuller picture of the patient-at-home and increases the ability of the clinician to fine tune the patient's care, help maintain patients at home and increase patient satisfaction. They are available to meet with patients and families. Their functions include:
o In office and home visits
o Support to caregivers and families
o Making referrals to therapists and support groups
o Helping resolve complicated situations such as isolation, stress or safety
o Helping seniors and families with life span planning
o Connecting patients with community resources & elder services
o In office and home visits
o Support to caregivers and families
o Making referrals to therapists and support groups
o Helping resolve complicated situations such as isolation, stress or safety
o Helping seniors and families with life span planning
o Connecting patients with community resources & elder services
The practice of case management varies greatly across social work settings and is even more diverse as applied by other professionals. Despite this diversity, several elements distinguish social work case management from other forms of case management.
Social work case management is a method of providing services whereby a professional social worker assesses the needs of the client and the client’s family, when appropriate, and arranges, coordinates, monitors., evaluates, and advocates for a package of multiple services to meet the specific client’s complex needs. A professional social worker is the primary provider of social work case management. Distinct from other forms of case management, social work case management addresses both the individual client’s biopsychosocial status as well as the state of the social system in which case management operates. Social work case management is both micro and macro in nature: intervention occurs at both the client and system levels. It requires the social worker to develop and maintain a therapeutic relationship with the client, which may include linking the client with systems that provide him or her with needed services, resources, and opportunities. Services provided under the rubric of social work case management practice may be located in a single agency or may be spread across numerous agencies or organizations.
The primary goal of case management is to optimize client functioning by providing quality services in the most efficient and effective manner to individuals with multiple complex needs. Like all methods of social work practice, case management rests on a foundation of professional training, values, knowledge, theory, and skills used in the service of attaining goals that are established in conjunction with the client and the client’s family, when appropriate. Such goals include:
Social work case management is a method of providing services whereby a professional social worker assesses the needs of the client and the client’s family, when appropriate, and arranges, coordinates, monitors., evaluates, and advocates for a package of multiple services to meet the specific client’s complex needs. A professional social worker is the primary provider of social work case management. Distinct from other forms of case management, social work case management addresses both the individual client’s biopsychosocial status as well as the state of the social system in which case management operates. Social work case management is both micro and macro in nature: intervention occurs at both the client and system levels. It requires the social worker to develop and maintain a therapeutic relationship with the client, which may include linking the client with systems that provide him or her with needed services, resources, and opportunities. Services provided under the rubric of social work case management practice may be located in a single agency or may be spread across numerous agencies or organizations.
The primary goal of case management is to optimize client functioning by providing quality services in the most efficient and effective manner to individuals with multiple complex needs. Like all methods of social work practice, case management rests on a foundation of professional training, values, knowledge, theory, and skills used in the service of attaining goals that are established in conjunction with the client and the client’s family, when appropriate. Such goals include:
- enhancing developmental, problem- solving, and coping capacities of clients
- creating and promoting the effective and humane operation of systems that provide resources and services to people
- linking people with systems that provide them with resources, services, and opportunities
- improving the scope and capacity of the delivery system
- contributing to the development and improvement of social policy.
HEALTH COACH
Christina Stoker, CHWC
617-798-0752
[email protected]
Providing health coaching for patients with the following insurances:
Medicare ACO, Tufts Medicare Preferred, BCBS HMO, HCHP
Medicare ACO, Tufts Medicare Preferred, BCBS HMO, HCHP
Targeted Chronic Diseases:
- Diabetes
- Cardiovascular Disease
- History of ischemic heart disease, coronary procedure, Congestive Heart Failure, Stroke
- Hypertension
- COPD
- Any of the above when associated with depression or depressive symptoms
Health Coach Interventions:
- Goal setting protocol for chonic disease management
- Making in-person connection with patient
- Weekly phone calls
- Home visits
- Encourage follow up with PCP and specialists
- Medication adherence support
- Therapy and support group referrals
- Daily diabetes logs
- Nutritional counseling
- Activity logs
- Review by MACIPA Systematic Case Review Team members : endocrinologist, pharmacist, psychiatrist, health coaches
