The Care Management Process
Care Plan Development
The RN Care Manager with oversight by ForeSee Health’s Medical Director will assess the participant’s overall health status and collaborate with the participant and participant’s physician to design an individualized care plan. The care plan addresses those factors that place the participant at risk for ER visits and hospitalizations. The plan also supports the participant’s desires for improved health and quality of life. Some of the areas included in the participant’s care plan are: Setting goals and target dates for improvement; Helping participant access and understand needed medical services Determining participant’s educational needs Coaching for self-management skills and lifestyle changes; Change readiness strategies; Removal of barriers to adherence; Risk-factor modification Ensuring compliance with physician visits, medications, and preventive activities