Care Management

CABS Care Management, a division of CABS Home Attendants Service, Inc.  Our mission is to assist our clients in managing and mastering their daily living activities.  Our Care Manager will work with clients to assess the life areas that can be made better and work with you to develop a care plan to help you reach your goals and improve your overall health and wellbeing.

We will work with you to:

• ensure that you are linked to medical services
• assist with medical appointments
• seek out needed entitlements
• assist with treatment adherence
• provide housing assistance
• and much more.

Components of our Care Coordination Process

Outreach and engagement

Our care team learns about everyone’s needs—such as life and health goals, past treatment experiences and preferences, strengths and resources, and barriers they face.  We design strategies to foster ongoing relationships with the individual at the center of their care plan.

Comprehensive assessments 

Each client goes through a thorough evaluation focused on exploring several life areas, including medical, behavioral, social, legal, housing, and other core areas. It is designed to capture the patient’s history, identify current areas of need and existing providers.

Individualized care planning

The client care plan addresses personal wellness goals, objectives, and interventions needed to reach optimal health and functioning adequately.

 Referrals to community partners

Referrals are made with attention to member preference, geographic proximity, and collocation of needed services.  Our team has extensive relationships in the community to support patients in meeting their care plan goals, preventing the escalation of care needs, and reducing the need for emergency or high-intensity care.

 Coordination of benefits enrollment

We assist with Medicaid application and recertification as needed to ensure that patients maintain their insurance coverage.

Who is eligible for Care Management services? – Create a checklist  take the one from the care management tri-fold flyer

If you or someone you know can answer “Yes” to all the six questions below, then we could assist you in getting Care Management Services:

• Do you have two or more chronic or mental health conditions for which you need regular doctor’s care?
• Do you find it difficult to see a doctor when you need to?
• Have you been into or thought about going to the emergency room several times over the past six or twelve months?
• Do you feel unsafe at home, or would you need a safe place to live?
• Do you feel isolated and would want someone to assist you when you need help?
• Do you have difficulty keeping medical appointments?

Experience in Care Management

CABS has been engaged in Care Management for the last 40 years but never been able to bill for it until it participated in the DSRIP partnership within the OneCity Health PPS to provide Community Health Worker (CHW) services for the Asthma Project in the Pediatric Ambulatory Care setting and Pediatric private practice. Our Community Health Workers provide home environmental assessments to help self-management of chronic illness for re-hospitalization prevention.