Targeted Case Management

Various issues exist in the care of clients that lead to the worsening of medical conditions, additional care needs, and an ongoing rise in healthcare costs. Working collaboratively with providers, a case manager can help resolve these issues and improve health outcomes in clients with complex medical and care needs. 

Our case management team uses the Ambulatory Integration of the Medical and Social Care Model (AIMS) to help address our clients' medical and non-medical needs. This protocol ensures that clients are heard and included in their care and includes:

• Client engagement: The case manager meets with the client and validates their concerns, answers questions, and provides guidance and resources to help navigate clients through their care plan.
• Assessment and development: The case manager collects information and works with the client to develop a comprehensive care plan, identifying social and environmental factors that may affect the client's treatment plan and healthcare outcomes.
• Case management: The case manager helps clients to stay on track with their care plan and makes sure they have the support they need.
• Ongoing care as needed: The case manager continues to support the client as needed, making changes when necessary.