Page 111 - Business Development Orientation Binder

4/9/2019

VNSNY Care Management :

• Comprehensive assessment of health, psychosocial, functional and
environmental factors
• Customized care plan includes assistance with ADLs and IADLs, medication
management, nutrition, home safety and household arrangements
• Advocacy, education, oversight and care coordination by specially trained
Registered Nurses and Social Workers overseeing an interdisciplinary team
• Clinical experience navigating complex care needs across providers and other
healthcare settings, with expertise in disease-based care, including:
− Multiple Sclerosis, Alzheimer’s and related dementias, Heart Disease
− Parkinson’s, Cancer, Diabetes
Partners in Care • Coordination with patient’s physicians and ensure medical appointments are
scheduled
• Status updates and new findings to family caregivers
• Assistance with finances, legal questions, community linkages
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Skilled Nursing:

• Skilled nursing LPN or RN.
− Infusion
− Wound Care treatments
− Catheter
− Diabetic Care
− Tube feeding
− Pulmonary care
− Medication management and administration
− Immunization services
• PRI/Screen Clinical assessments of patients’ medical conditions & home safety
Partners in Care − Nursing Home placement screening using PRI (Patient Review Instrument as
required by the NYS to determine eligibility)
− Home safety assessments conducted in-home by a Registered Nurse

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