Patient Care Management

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Patient Care Management is a set of activities intended to improve patient care and reduce the need for medical services by helping patients and caregivers more effectively manage health conditions.

SouthCoast Health is pleased to offer patient care management.  Team-based, patient-centered services are designed to assist patients and their support systems in managing medical conditions more effectively.  It encompasses care coordination activities needed to help manage chronic illnesses

Chronic Care Management

Our chronic care management program provides non face-to-face services to Medicare beneficiaries who have multiple, chronic conditions. All enrollees will be assigned to a Chronic Care Manager who provides ongoing assistance. The program is designed to assist patients with medication adherence, scheduling appointments, education on chronic conditions and providing resources to assist in your care. Our goal is to help you reduce your out of pocket cost and provide you with the best care possible. For more information or to enroll in this program, please talk to your primary care physician.

Accountable Care Organization (ACO) Care Coordination

The ACO care coordination program consist of physicians, hospitals and other healthcare providers; working together coming together of shared decision making.  Services are provided to Medicare B beneficiaries. Out program is designed to increase quality and overall care for our patients. Please discuss program with your provider during your next office visit.

Behavioral Health Services

At SouthCoast Health we care about your total well-being. We understand that our patients may experience mental illness or substance abuse disorders.  We currently provide social services by a licensed social worker, for our adult population.  If needed, resources can be provided for our pediatric population. Please discuss a referral need with your provider during your next office visit.

Resources:

Mental Health Services

Drug Abuse and Drug Addiction

Suicidal Ideation - Adult

Transition of Care

At SouthCoast health our goal is to improve the effectiveness of transition of care between organizations. If you have recently been discharged from any of the area hospitals or in-patient facilities, please contact your primary care physician to schedule a follow up appointment

Self-Management Tracking Tools

Blood Pressure Log

Blood Glucose Log

Daily Food Diary

Fitness Diary