Working together
to make today a good day
Each day can present a new set of challenges. Getting a little help now and again can make a world of difference. The Care GuidanceSM Program offers you the support you need to maintain or improve your health. You'll receive additional healthcare services, resources and information at no additional expense to participants beyond your regular Medicare costs (premium, deductibles, and co-payments) and without any change to the doctors, healthcare providers, hospitals and pharmacies you currently use. While only a select group of Medicare beneficiaries have been invited to participate in this three-year Medicare demonstration project, the Care Guidance Program is part of a nationwide campaign to enhance healthcare services in the future. Participation in the program is voluntary and without obligation.
In order to fully understand your medical needs and concerns and to help you manage your healthcare, we ask that all program participants complete an interview with a Care Manager. Although an interview is not required for program participation, we ask that all participants consider completing one. These interviews are confidential and conducted over the phone with a Care Manager, who will use the information you provide to identify and recommend any services that may be appropriate for your specific needs or issues. If you have already completed an interview, we’d like to thank you for your time and cooperation. If you have not completed an interview, we encourage you to do so. Please call 1-888-667-8447 to schedule your interview so that we can better serve you.
Program Highlights
Frequently Asked Questions
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Contact the Care Guidance Program
Program Highlights
The program includes:
Personal Attention and Care Coordination
Every participant is offered the personal one-on-one assistance of a Care Manager. These experienced professionals can provide important health information, teach self-care skills and assist in medical care coordination. Care Managers are only a phone call away to answer your questions, encourage you to follow your treatment plans, and make sure that the right care is received at the right time.
Coordination of Care Between You and Your Doctors
Your Care Manager can coordinate health-related services and ensure that all of your providers are aware of all your medical issues.
Medication Management
Your Care Manager will help you understand prescriptions, drug interactions and the importance of following medication plans. In addition, a consultation with the Care Guidance Program’s pharmacist is available to participants with medication related concerns as well as those with certain conditions like Diabetes, Heart Failure and Asthma or Chronic Obstructive Pulmonary Disease(COPD). The Care Guidance Program Staff can also help with questions about Medicare Part D and other pharmacy programs such as the New York State Elderly Pharmaceutical Insurance Coverage (EPIC) Program. Click the following links for additional information:
Medicare Part D Information 1-800-MEDICARE (1-800-633-4227)
NY State EPIC Program Information 1-800-332-3742
Nutritional Support and Education
A telephonic consultation with the Program’s nutritionist is available to participants who are on special diets or have other nutritional concerns.
Falls Prevention
Screening is available to help identify issues that may put you at risk for falling. Educational materials about how to prevent falls both inside and outside the home are available. For participants who are at high risk for falls, the program offers a comprehensive consultation with a geriatrician specifically focused on reducing your risk of falling.
Assistance with Life Planning (Advanced Directives)
Participants are offered assistance in preparing a Living Will, identifying a Healthcare Proxy and talking about these important Life Planning decisions with family members and healthcare providers.
- The New York Health Care Proxy lets you name someone to make decisions about your medical care, including decisions about life support, if you can no longer speak for yourself.
- The New York Living Will lets you state your wishes about medical care in the event that you develop an irreversible condition that prevents you from making your own medical decisions.
You should complete these documents to ensure that you receive the medical care you want when you can no longer speak for yourself.
New York State Advanced Directives (Health Care Proxy and Living Will Forms)
New York State Health Care Proxy Information
In-home Health Monitoring Equipment (if needed)
The Care Guidance Program will soon be offering in-home monitoring for patients with Congestive Heart Failure. The monitoring device is a scale that transmits information over your telephone line to your Care Manager. This information is shared with your physician, as needed, who can then use it to help manage your care and prevent the need for hospitalization.
Community and Other Resources
Your Care Manager can help identify and facilitate referrals to appropriate community and other resources available to help meet your or your loved ones needs (eligibility rules and fees may apply). Frequently used programs include:
- Access-A-Ride (AAR) 1-877-337-2017
Provides transportation for people with disabilities who are unable to use public bus or subway service for some or all of their trips.
- Expanded In-home Services for the Elderly (EISEP)
Services include non-medical in-home services such as housekeeping, personal care, respite, case management and related services (such as emergency response systems).
- Telephonic Reassurance and Friendly-Visiting Programs
These programs are available in some communities and are typically provided by volunteers working with faith-based and other community organizations. These programs are recommended for people who live alone and have a difficult time getting out of their homes.
- Caregivers Support and Respite Programs
A caregiver refers to a person, either paid or voluntary, who helps a disabled or older person with the activities of daily living, health care, financial matters, guidance, companionship and social interaction. Most often the caregiver is a family member or friend who aids the person. Care Guidance program staff can also provide information and assistance to caregivers, including information and referrals for support services, such as 24/7 help lines, support groups, educational programs, national associations and respite care programs. Respite Care is time off for the caregiver. Services can include anything from in-home care; adult day care; assisted living facility; or nursing home care.
- MD House Calls Program
Participants who are homebound and find it extremely hard to get to their doctor may be eligible for the Montefiore MD House Calls Program. This program, staffed by physicians and nurse practitioners, provides comprehensive primary care in the comfort of your own home.
- Personal Emergency Response Systems (PERS)
Some participants, particularly those who live alone, may benefit from PERS; a button system worn as a necklace or bracelet, that alerts medical personnel if you are in need of emergency medical assistance when the button is pressed. Your Care Manager can provide you with a list of companies that will provide this service.
- Free or Low Cost Dental Care
A number of dental providers in the Bronx offer free or low cost services for individuals with limited income and resources. Your Care Guidance Care Manager can provide you with a list of dental providers in your area.
Frequently Asked Questions
When should I call my Care Manager?
Call your Care Guidance Care Manager at 1-888-667-8447 if and when you:
- Have questions about your healthcare
- Would like help to get healthcare services
- Have recently been to the emergency room or admitted to the hospital
- Have fallen, even if you do not hurt yourself
- Have had a significant change in your life or health
If I have been selected, is there any additional cost for the Care Guidance Program?
There is absolutely no additional expense to participants beyond your regular Medicare costs (premium, deductibles, and co-payments). Medicare is working with Montefiore Medical Center to provide these services at no additional cost to you. By keeping you at your optimal health, everyone benefits.
Will I need to change doctors, hospitals or pharmacies?
You can use your own primary care doctor, choose your own specialists and receive treatment from any hospital or treatment facility you choose, not just Montefiore, and not just in the Bronx.
Will I need to travel or visit doctors, clinics or hospitals to receive services?
You do not have to leave your home to participate in the Care Guidance Program. Most of the Care Guidance Program services are provided by telephone, in-home monitoring equipment or in some cases by a healthcare professional visiting you in your home. You can make the decision to accept or refuse any services offered to you.
Will there be any changes to my Medicare benefits?
Your current Medicare benefits and existing Medicare coverage will not change. You will continue to have the same services that you already have. You get all the additional benefits of the Care Guidance Program at no extra cost.
Can anyone enroll in the Care Guidance Program?
Enrollment and eligibility in the program are restricted. The Care Guidance Program is not available to everyone. You must be selected by Medicare to qualify for the program.
Why was I invited to participate in the Care Guidance Program?
Medicare invited beneficiaries in the Bronx who might benefit the most from the program. Participation in the program is completely voluntary, and you can choose to end participation at any time.
Do I have to have a serious medical condition to participate in the Care Guidance Program?
No. If you are currently healthy, we want to help you stay that way. If you are currently suffering from a short-term illness or ongoing condition, we want to help you maintain or improve your health. The Care Guidance Program is personalized to meet the special needs of the people we serve. |
