Medical case manager driven population management
Nurse case managers regularly review caseloads for patients we have not seen recently and personally reach out to them using multiple and personalized methods. We discuss missing people in community case conference, asking for assistance in helping keep people engaged in care.
Developing skills in assessing barriers for patients and following up with referrals made for social services and support
Poverty creating social barriers to housing, food, transportation
Rural setting creating time and distance between pt and services
Substance abuse/mental health issues
Misunderstanding btw provider and patient
You may only upload PNG, JPG, or GIF files