Complex Care Management

People managing one or more chronic medical conditions face a variety of issues. It may be difficult to follow the doctor’s care plan because of transportation issues, or confusion understanding multiple different medications. Complex care management can help patients deal with the challenges of life with a complex condition.

When patients come to us for help managing their medical situation, our first step is to schedule an in-depth, hour-long intake session to help us understand their situation. We strongly recommend the patient bring a caregiver, friend, or family member to help take notes.

New patients are assigned a nurse navigator to serve as their care “point person” and provide guidance, advocacy, education, and support. We use a coordinated care model to deliver the following services:

  • Symptom management for pain, anxiety, nausea, and other issues affecting a patient’s quality of life
  • Prescription of pain medication pending approval from the patient’s doctor
  • Assistance navigating the healthcare system
  • Access to a variety of MarinHealth services including:
    • Diabetes education and support from the MarinHealth Braden Diabetes Center
    • Integrative modalities at the MarinHealth Integrative Wellness Center
    • Telehealth access to complex care
  • Referrals to our partners in the care community who can provide services that fit the patient’s medical, personal, and financial situations