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RN-led Care Coordination

More than advice. A primary RN who stays involved.

When appointments, medication changes, tests, referrals, providers, equipment, and family responsibilities all move at once, Embrace helps keep the plan visible and the next steps moving.

Request a coordination consultation

The problem

The family becomes the care coordinator by default.

Every provider manages one part. The family is left to remember appointments, reconcile instructions, follow up on referrals, arrange transportation, track testing, and explain changes to everyone else. That burden grows fast when the family lives at a distance or the client’s needs keep changing.

Care Coordination may help when

  • Several providers or services are involved
  • Appointments, tests, referrals, or instructions are being missed
  • Medication changes create questions or confusion
  • An ER visit, hospitalization, or reported change disrupted the plan
  • Family members need authorized updates and clearer responsibilities
  • The client wants support staying safe and independent at home

What is included

Ongoing RN involvement, built around the person and the plan.

A primary RN learns the client’s needs, understands the goals, and remains involved instead of offering a one-time recommendation and disappearing.

01

Two RN visits

Two scheduled RN visits each month to reassess, review concerns, and support the plan.

02

Appointments

Prepare, attend when requested and scheduled, track follow-up, and address practical barriers.

03

Care changes

Track provider-directed medication changes, tests, referrals, instructions, and next steps.

04

Communication

With authorization, coordinate the care team and keep the client and family informed after an ER visit, hospitalization, or reported change.

How coordination works

Turn scattered information into owned next steps.

01ListenUnderstand the client’s goals, routines, concerns, and existing support.
02OrganizeMake appointments, changes, open questions, and responsibilities visible.
03CoordinateHelp the right people connect and address barriers within the authorized scope.
04Follow throughTrack what happened, what is still open, and what needs to change next.

How we work with each audience

Coordination should reduce confusion, not create another layer.

Client

Your goals stay visible.

We explain priorities in plain language and keep comfort, independence, routines, and preferences central to the plan.

Family caregiver

You gain a map and a partner.

We clarify what you own, what others own, what is still open, and when the plan needs to change.

Referral partner

Authorized follow-through.

We reinforce the plan at home, coordinate nonmedical barriers, and communicate appropriate status with authorization.

Care Coordination does not replace a physician, skilled home health, therapy, emergency care, or a legal or financial advisor. Embrace does not diagnose, prescribe, or independently change medications.

Start with a conversation

You do not have to coordinate every moving piece alone.

Tell us what is becoming difficult to manage. We will explain the assessment, service fit, and next step.

Call 405-735-7166Contact Embrace