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Anoka, Minnesota

2006 N 1st Ave Ste 205 , Anoka, MN 55303

(763) 786-1000

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How RN Care Management Improves Outcomes

Doctor talking with her patient

Staying and Saving at Home with RN Care Management

The RN Care Management Process is designed to assist your patients or clients get exactly the services they need. Helping them be successful improving or maintaining their health and living in their own home. We integrate the use of a Registered Nurse along with our Care Coordinators to provide a level of care that help make it possible to live safely and happily at home. RN Care plans make sense both from a health and financial basis. Insurance companies often provide these plans when someone is frequently hospitalized. They know the cost of medical treatments go down when they utilize an RN to work with their customers. Using the same philosophy, starting before they have frequent medical emergencies, we can keep seniors in their home longer and at less expense by assisting them in maintaining better health. Often, their home is paid for and the remaining expenses are taxes and city services, like sewer and water. Hiring someone to cut the lawn and shovel the driveway is a fairly simple process along with many other jobs that can be done by a handyman. If seniors are safe, staying at home can save a lot of money vs. a facility. Take a look at the Aging in Place Cost Calculator and feel free to share it with people struggling with decisions about moving to a facility.

Starting Out with RN Care Management

The first step in the process is to set up a free RN assessment. A Comfort Keeper RN will come out to the home and meet with the senior and family to put together a comprehensive plan that meets their needs. If they feel good about the plan, the nurse can get them started right away. If, for instance, someone is in the hospital or nursing home, the nurse or care coordinator can come out and meet with them and attend any care conferences. This is a great way to start on the right foot and put together a complete plan of care to help them stay healthy at home.


Elements of a Customizable RN Care Management Plan

  • Medication management
  • Identifying and addressing any home safety concerns
  • Troubleshooting changes and challenges
  • Advocating for the client with other resources and services
  • Providing communication hub through use of the Family Room for all questions by family and client, especially families living at a distance
  • Providing caregiving oversight to coordinate, oversee, and be accountable for any caregiving services involved, including supervising and training caregivers
  • Working with client, family and other resources, facilitating family care meetings and planning for client
  • Protecting/promoting client independence by identifying and developing a plan of care to achieve goals
  • Providing ongoing education and guidance to the client and their family
  • Coordinating transportation for any activity, including accompanying to physician appointments
  • Assisting with any relocation, including tours and move coordination; assesses and analyzes living options to help identify ‘best fit’.
  • Helping plan and coordinate resources for seasonal needs including yard work, home cleaning, snow/leaf removal, and decorating.
  • Encouraging/assisting client in maintaining social activities and hobbies
  • Available 24/7 for concerns or problems that arise


What Happens After Sign Up?

Within 48 hours of sign up, an RN Care Manager visits the client at home and develops a Plan of Care. During this visit, the RN Care Manager will gather information to educate the client and their family on his or her disease management, medication administration, nutritional needs, and home safety to promote the client being able to live healthy at home. Within one week of beginning services, the RN Care Manager coordinates any necessary appointments with the primary care provider or other specialists as determined during the assessment, with input from the client and family. The RN Care Manager will help the client and family members assess other needed resources such as home delivery of meals, transportation to doctor appointments, and ensuring all prescribed medication is in the home. Having these tasks done is a large step toward changing the environment that may have contributed to the previous medical issues and avoid future complications.

Client Care Coordinators Provide Support

Our client Care Coordinators assist the RN with other professional resources like physical therapy, home handymen, or cleaning services. Let’s say a key component to keep them safe at home is being able to get safely around their environment. The RN and Care Coordinator will team up to make sure a home safety assessment takes place to reduce any issues right from the start. They can also work with one of our community partners to set up additional services. For example, an assessment for physical therapy. The therapist would either come to the home or we would arrange transportation to their facility. They would work with the patient to determine a treatment plan. The therapist can also work with their insurance company to help understand any financial obligations for their services--generally they are covered by most plans. In this example they would likely strive to build up the seniors strength and balance--perhaps suggest grab bars or other physical enhancements to the home. We can also help get those installed through a Care Coordinator. Imagine the family caregiver not having to chase down every detail which helps provide better compliance to the plan and a more stable environment.

Ongoing Care and Support

Once we have a program in place, it can change with client needs. For instance, if they have a medical appointment with a specialist and want a nurse along to help everyone understand the situation better, we can add that to a plan--even on a one time basis. If, for instance, your patient or client was hospitalized for some reason, the RN will create a new Care Plan as soon as they are discharged to make sure to avoid a downward spiral that could take them away from the home. If they need additional services during their recovery from an illness, we have Certified Nursing Assistants and Home Health Aides available to help them recover at home.

Materials for Professionals

To Help you assist people that might benefit from this service, we have developed a Care Management Package which includes:

  • Informational handout on RN Care Management
  • Pricing information
  • File of Life
  • Checklist of items to prepare for a free RN Consultation

This can be provided to you in a PDF (without the File of Life) or mailed to you.  


Mail Me a Package!   Download the Package!




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