Martin’s Point Health Care is partnering with Health Quality Partners to deliver advanced, community-based preventive care and care management interventions for chronically ill older adults. The HQP model of care focuses on the following:
• Management/prevention of the onset or complications from common chronic diseases – heart failure, coronary artery disease, chronic lung disease, depression, and diabetes
• Avoiding complications and preventing hospitalizations associated with chronic conditions and aging
• Promoting safety and independence and optimizing physical and social functioning
• Assisting with and facilitate long term advanced care planning
The Community Care Nurse provides comprehensive, person-centered, longitudinal community based advanced preventive care and care management (CM) interventions for participants and families enrolled in the Comprehensive Care Program. Effectively engages, assesses, monitors, educates, coordinates, and provides interventions for participants and families to improve the quality of care and participant health outcomes. This role reduces unnecessary health care utilization. Collaborates with physicians, hospitals, skilled nursing facilities, home health providers and community services to advocate for participant-centered goals and needs, to promote better health, and to prevent unnecessary hospital utilization.