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Navigating Complex Care
So Patients and Families Don't Have To
HPG's multidisciplinary case management team -- physicians, APRNs, LPNs, and licensed social workers -- coordinates the full spectrum of care needs from direct hospital admissions to PASRR evaluations and beyond.
What HPG Case Management Does
From the moment a complex care need arises, HPG's case managers work across facilities, systems, and agencies to ensure coordinated care without gaps.
Direct Hospital Admissions
HPG physicians can directly admit patients to partner hospitals and skilled nursing facilities -- bypassing the ER when clinically appropriate, reducing patient stress, and ensuring continuity of care with a known physician.
PASRR Evaluations
Pre-Admission Screening and Resident Review (PASRR) evaluations are federally required before SNF admission for patients with mental illness or intellectual disabilities. HPG's team completes Level I screenings and coordinates Level II evaluations.
3008 Form Completion
Florida Medicaid requires the AHCA 3008 Physician Certification Form for long-term care placement. HPG's providers complete these forms accurately and promptly to facilitate timely placements.
Care Transitions Coordination
Coordination across hospital, SNF, ALF, rehab, home care, and clinic settings. Case managers ensure nothing falls through the cracks when patients move between levels of care.
Social Services Navigation
Licensed social workers identify and address social determinants of health -- housing instability, food insecurity, transportation barriers, financial hardship -- and connect patients with community resources and benefits programs.
Family & Caregiver Coordination
Keeping families informed and involved in care decisions. HPG's case managers communicate with family members, help navigate care options, and support the patient's expressed goals and wishes.
The Case Management Process
Our case managers follow a structured process to ensure every patient's complex needs are met with precision and care.
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Referral & Initial Assessment
A case management need is identified -- by a physician, facility, family member, or patient. An HPG case manager conducts an initial assessment of medical, functional, psychological, and social needs.
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Care Plan Development
Working with the patient's physician and interdisciplinary team, the case manager develops an individualized care plan that addresses immediate needs and long-term goals.
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Documentation & Regulatory Compliance
PASRR forms, 3008 certifications, prior authorizations, and other required documentation are completed accurately and submitted promptly to avoid placement delays.
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Facility & Service Coordination
The case manager coordinates directly with receiving facilities, home health agencies, DME suppliers, and community services to arrange the right level of care at the right time.
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Ongoing Monitoring & Adjustment
After placement or transition, the case manager continues to monitor the patient's status, adjust the care plan as needs change, and intervene proactively to prevent avoidable crises.
Key Forms & Regulatory Processes
HPG's case management team is experienced with Florida's long-term care regulatory requirements -- ensuring timely and compliant documentation for every patient.
Required by Florida Medicaid for long-term care placement. Certifies that a patient requires the level of care provided in a nursing facility. HPG physicians complete these promptly.
Pre-Admission Screening and Resident Review -- federally mandated for all Medicaid-funded SNF admissions involving mental illness or intellectual/developmental disabilities.
Clinical documentation and physician attestation for insurance prior authorizations -- SNF admissions, home health, DME, specialist referrals, and advanced diagnostics.
Case Management Across 14 Counties
HPG's case management team operates across Central Florida's 14-county service area -- coordinating with local facilities, agencies, and services in each community.
Need Case Management Support?
Our case management team is ready to help navigate complex care situations. Call us or reach out online today.
We accept Medicare and most major insurance plans. Call to verify your coverage.