Piedmont Atlanta Hospital's community-based care management program assists low-income, high-risk patients with chronic conditions through coordinated community-based follow-up care and appropriate community resource support. This program is made possible by the generous support of Kaiser Foundation Healthcare of Georgia.
Chronic illness expense, care, and management are problems for many Americans, particularly low income populations, including those with insurance as well as those without. In partnership with Kaiser Foundation Healthcare of Georgia, Piedmont Atlanta will work to relieve the burden of chronic illness through aggressive community based care management.
We will work to boost the health of high risk, low income patients with complex chronic illness by providing community-based follow-up care provided by a registered nurse care manager; assistance with patient and caregiver health self-management skills as to better maintain an individualized care plan; transportation to access hospital- or office-based follow-up care; assistance with the cost of medication; and, assistance with purchasing durable medical equipment, such as weight scales, glucose monitors and other diagnostic tools to ensure health self-management. This will allow our patients and caregivers to develop the skills to better self manage their health and healthcare resources, improve quality of life for both patients and caregivers, and decrease preventable re-admissions and re-encounters in emergency departments.
For more information, please contact Piedmont Atlanta’s patient care coordination department at (404) 605-5955.