At Sierra Care, our case managers are caring, dedicated patient advocacy professionals who facilitate communication between patients, medical teams, and families during subacute and long-term rehabilitative care.
A case manager works closely with individual patients and their families, referring case managers, discharge planners, and other personnel involved in each case to ensure a streamlined recovery experience. When you or your loved one experiences a severe medical problem that necessitates acute rehab, a case manager serves as a touchpoint to support you through each step of your individualized recovery plan. At Sierra Care in California, our case managers are experienced professionals dedicated to supporting patients through each phase of treatment.
We understand that working with insurance companies can be complicated. Our case management services protocols ensure that our care meets medical guidelines set by your health insurance company, commercial insurance company, independent physician group, workers’ compensation, or other parties responsible for payment.
Case Management at Sierra Care
At Sierra Care, our case managers follow industry-wide best practices, providing care coordination, patient advocacy, safe discharge planning, and family engagement meetings.
| Case Management Service Pillar | Involved Parties | Benefit to Patient |
|---|---|---|
| Care Coordination | Patient, Sierra Care case manager, physicians, specialists, hospital case manager, family, insurance providers, and more | Sierra Care case managers work with all involved parties to coordinate streamlined, patient-first care plans, providing clear communication throughout a streamlined admissions process. |
| Patient Advocacy | Patient, Sierra Care case manager, physicians, therapists, specialists, and more | Each Sierra Care case manager works as a point of contact for their patients, constantly prioritizing individual medical, emotional, and personal needs during their subacute care treatment plan. |
| Safe Discharge Planning | Patient, Sierra Care case manager, family, and the case manager at the destination facility | At Sierra Care, our case managers take a proactive approach to the discharge process, ensuring a safe, smooth transition to home, outpatient care, or other care facilities. |
| Family Engagement & Meetings | Patient, Sierra Care case manager, physicians, therapists, specialists, and family | Family support is key during subacute care. Sierra Care case managers foster regular communication with loved ones through scheduled updates, regular care plan meetings, and collaborative decision-making. |
Providing Continuity of Care from Pre-Admission to Discharge
We recognize that your recovery journey begins before you enter our facility and continues long after you return to your daily life. Your case manager will serve as your advocate through each phase of subacute care.
Here’s what you can expect from your case manager at Sierra Care.
Pre-Admission and Admission
Your case manager will get to know you and learn more about your care needs. While a number of care providers will be included in your pre-admission screening, your case manager will be your point person throughout the pre-admission and admission process. In both the days leading up to your admission and the admission process itself, your case manager will coordinate your care, keep your family informed of your status, and learn more about your unique needs. Your care manager will work to facilitate your transition from your acute care facility to Sierra Care and will work with you to secure any necessary insurance coverage and authorizations.
Needs Assessment
After the intake process is complete, your case manager will continue to identify your problems and needs, ensuring that your personalized treatment plan is setting you up for success. Your case manager may also work with you and your treatment team to determine treatment goals, helping you and all parties involved (including your family) get on the same page regarding your treatment and progress. Your case manager may also talk with you about any risks or challenges that you may encounter throughout the treatment process.
Over the course of your treatment, your case manager will check in with you and your treatment team to reassess your needs, ensuring your treatment plan is still working to bring you closer to your pre-discharge goals.
Service Planning
During the service planning period, your case manager will break down your larger goals into tasks and specific objectives. Combined with the information gathered during your pre-admission, admission, and needs assessment processes, this can help ensure your goals are timely, measurable, and set you up for success after you complete your subacute treatment plan at Sierra Care. Your case manager will work to inform all stakeholders in your care — including your family and treatment team — about your goals and progress throughout the course of your treatment.
Progress Monitoring
After your needs, goals, and treatment plan are in motion, your case manager will continue to track your progress, making adjustments as necessary. Since your case manager already understands your needs and has been with you since the pre-admissions phase, they’ll be able to easily see a clear picture of your progress, providing patient care coordination while advocating for changes to your treatment plan to keep you on the path to recovery. Your case manager will use the metrics developed during the service planning process to ensure that quantifiable data is used to determine your progress as you prepare to exit subacute care.
Discharge Planning
As you meet your treatment goals and your subacute care treatment plan comes to a close, your case manager will work with you and your family to help you transition to your next level of care. Depending on your needs, you may move to outpatient therapy, home-based care, a skilled nursing facility, a long-term care facility, or another treatment option. Your case manager will work with you to find safe discharge planning options that make sense for your needs, your insurance plan, and your level of recovery.
Supporting Patients and Families Through Each Transition
Your family is an important part of your recovery. Our regular family care meetings allow your loved ones to talk with your Sierra Care case manager, gaining valuable information that will help your family support you after you complete the subacute period of care.
Why Should You Choose Sierra Care?
At Sierra Care, our team provides compassionate, positive, research-backed care through every step of the rehabilitative process, allowing you to rest assured that you or your loved one is receiving state-of-the-art care that will help you return to a full, enjoyable life.
Our 24-hour congregate living health facilities in Springville and Clovis offer subacute care for patients undergoing recuperative treatments for a number of conditions, including:
- Spinal cord injuries
- Traumatic brain injuries
- Neuromuscular conditions
- Congenital conditions
- Other medically complex injuries
Our industry-leading physicians work closely with neuropsychological specialists, nurses, therapists, activity directors, social workers, dietitians, respiratory therapists, and case manage
Our Specialized and Experienced Caregivers
Sierra Care’s Patient Care Team
Sierra Care Difference
Sierra Care offers around-the-clock, 24/7 subacute level of care to our patients, many of whom present with medically complex conditions. Even in cases that require attention from multiple specialized areas, Sierra Care is able to look at the individual’s needs as a whole and custom-tailor their recovery plans. Our spotless, peaceful facilities with breathtaking views provide a pathway to recovery that gives you and your loved ones the keys to a bright, healthy future. Only at Sierra Care can you find this degree of one-on-one personalized treatment combined with 24-hour inpatient care.
Better Case Management
Our skilled nurses, case managers and expert physicians are some of the best in their field, and they are emotionally invested in your journey towards healing. At Sierra Care, you’ll have access to a medical staff who are able to provide complex multi-disciplinary treatments that are at the forefront of rehabilitation medicine. From catastrophic injury, to chronic conditions, and even an intentional focus on mental well-being and self-care, the nurses and doctors at Sierra Care are truly some of the most passionate healthcare workers you’ll find anywhere. Come visit us soon and find out what makes this team so special.
Subacute Level of Care
Sierra Care’s rehabilitation and recovery process operates 24-hours a day, 7-days a week. Our congregate living health facility features a team of nurses and rehabilitation therapists that is dedicated to helping patients during the in-facility rehabilitation process, as well as the process of transitioning to in-home care.
