Office Based Care Management is a program designed to improve the delivery of medical care to patients with complex chronic conditions. Your physician and his/her staff have been trained to use evidence based medicine, patient education and coaching and active follow-up to effectively coordinate your care and treatment. The care management program provides you with extra assistance to improve your health status and to prevent complications associated with your medical condition. The program is administered through a Care Manager who is a member of your primary care physicians “Care Team.”
A Care Manager is a nurse who will provide you with additional medical support and coordinate your care under the supervision of your physician. This may include scheduling you for office visits, outreach and telephone follow-up, education and coaching and other support to assist you in managing your medical condition. Your care manager can give you the extra assistance that you may need to meet your treatment goals.
All patients with multiple medical conditions are eligible for the Office Based Care Management program.
Patients in the Office Based Care Management program are identified by:
- Physician and practice team
- Hospitalizations and Emergency Room visits
- Self-referral – you can request to participate
- Medical conditions including kidney disease, COPD, congestive heart failure and other cardiac conditions
If at any time you feel that you are experiencing a life or limb threatening emergency, please call 911 and go to the nearest hospital emergency room. Some examples of these conditions include:
- Signs of a heart attack/ chest pain
- Signs of stroke, like sudden onset of numbness in any extremity
- Severe shortness of breath
- Heavy bleeding or bleeding that won’t stop after 10 minutes of direct pressure
- Complicated fractures (i.e. bone through the skin)
- Major injuries, such as head injury
- Unexplained drowsiness or disorientation
- Loss of consciousness
- Coughing up or vomiting blood
- High fever (104° or higher for a child; fever above 100.3 in an infant less than 3 months old)
- Suicidal or homicidal feelings
If you feel you need to visit a hospital emergency room for any other reason during the hours we are open please speak in advance with a Five Star Family Care provider. During the hours that we are closed, please contact the center for pre-recorded instructions on how to reach the after-hours, on-call physician. The Five Star physician may direct you to the ER or may advise you to be seen at Five Star promptly the next morning.
Five Star physicians practice in the office setting only. If you need hospital care, we will arrange for a specialist or hospitalist to care for you during your hospital stay. A hospitalist is a physician that only practices in the hospital and specializes in hospital based medicine. That physician will follow you and keep your Five Star Family Care physician up-to-date on your progress. He or she will also send a written report to us for your medical record.
If you have an ongoing medical condition, like high blood pressure or diabetes, you should try to see the same Five Star physician each time. To insure continuity of care, chronic conditions are best handled by a single physician. These appointments can be made online through the patient portal. All of our providers schedules are posted on our website as well.