Health Resources
Community Care Management Program
History of non-compliance with a medical health plan;
Six or more visits to the Emergency Room or physician within the last year;
Inpatient hospitalizations within the last year;
Significant weight loss and/or gain between visits;
Occurrence of falls lives alone;
Individuals with little or no social or family support system and caregiver breakdown;
Age 85+;
Difficulty managing bills and/or appointments;
Significant memory loss;
Significant hygiene/self-care problems;
Need for assistance with three or more activities of daily living;
Three or more chronic health problems;
Abuse issues;
A score of 25 or less on the mini-mental status exam;
Repetition of same thing/thought over and over.
Comprehensive assessments.
Screen, arrange and monitor in-home help and other services.
Assume short-term, interim or ongoing assistance for long distance or in-town caregiver.
Review and coordinate medical, legal and financial issues with appropriate services.
Provide crisis intervention.
Act as liaison for families with monthly status updates.
Provide ongoing communication with personal physician accompanying to appointments when appropriate.
Assist in placement of individual at appropriate level of support.
Provide consumer education and advocacy.
Ongoing screening, health education and intervention.
Offer counseling and support.
For more information about the Health Resources Program at Lakeshore CAP, please call (920) 683-2727 or (800) 924-0510 between 8AM-5PM or email Rhonda Trader at rtrader@lakeshorecap.org.
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