Social Work and Case Management Corner (last edit 1/10/2023)

Integrated AAH Care Management Vision

--Please open below 2021 Enterprise Population Health

Advocate Health Integrated Care Management integrates, coordinates, and simplifies the healthcare experience, impacting the Triple Aim and positioning Advocate to be successful, innovative, and sustainable in the current and future healthcare environments.

  • Improve the patient experience
  • Improve the health of patients we serve
  • Reduce the per capita cost of care

Ask why? and who?

Stakeholders: outpatient Case Managers (CMs) [Home; Physician Office]; ER CMs; Inpatient CMs, HaH HH CMs/SNFist-APN; OON UM

Compassionate Allowances Conditions

Patient may quality for Medicare earlier in life  ... due to:



2021 Enterprise Population Health Ambulatory Care Management Program Deck

2021 BCBSIL HMO Glucose Meter

2021 CCM Direct SNF Admission Process

2021 Cigna ESRD Meal Benefit Summary (9/14/2020)

2021 Humana Medicare Advantage Preferred DM Supplies

2021 Humana Over the Counter Catalog

2021 Oak Lawn IL SW CM Resources

2021 Payor CM Contact List

2021 Special Needs Cov Transporation IL_Chicago

2021 You have Been Referred aPlaceforMom

Training of Providers for Communicating Diagnosis for Providers

Dementia Care and Caregiver Support | Center to Advance Palliative Care (

Care Giver Resources

Alzheimer's Association Illinois Direct Form, (last accessed 2/26/2021)

Valuable resources for caregivers
(800) 563-4916 |
Caregiver Action Network
(202) 454-3970 |
Eldercare Locator
(a national directory of community services)
(800) 677-1116 |
Family Caregiver Alliance
(800) 445-8106 |
Medicare Hotline
(800) 633-4227 |
National Alliance for Caregiving
(301) 718-8444 |

If you are considering custodial care (Nursing Home), please look at:

On hearing and balance:

Poison control:!/exclusions


Seniors Helpline (Assist with Homemaker Services) 800-252-8966

Alzheimer's Association 24/7 helpline 800-2723900

Paratransit (transportation) 312-663-4357

Department of Aging - City of Chicago Senior Services: 312-744-4016 (please look at own area contact number),

--Home Delivered Meals

--Homemaker service: 80 hours of homemaker services.  Min 4 hours, max 8 hours per session, no nights

--Emergency response system

--gap funding grant

--Food box program

--Respite (ie care at home; does not apply if a family is paid as a care giver)

Needy Meds (assist with med sot)

Meals on Wheels (assist with food) 312-744-4016

Catholic Charities (Utilities, rent, food, housing etc) 847-376-2100

Life Alert (Medical alert Braclet) 800-517-8196

Lending Closet (assist with medical equipment)

Senior Companion Program 312-746-8572 or 312-743-0300

--Seniors provide company to other seniors (age 55 or older).  Can have homecare services in addition.

Complete a Power of Attorney (Spanish Patients) [available at the idph web site for English]

IL Movement

Related to mobility (not PD specific):
“A Matter of Balance” is available throughout Illinois and at several Advocate Aurora sites.  There are also several other Evidence Based Programs specific to falls that are offered through the Area Agency on Aging, which appears to be AgeOptions in the greater Chicagoland area.  Below is a link to some of the offerings.

Programs & Classes | Illinois Pathways to Health (
- Class Search (

Also, during conferences staff talk about:
-Parkinson Foundation:
Online Courses | Parkinson's Foundation

-Look for a Big And Loud Program/ LSVT LOUD

IL Housing

-Patient at or older than 60

--can get assistance from the Illinois Aging - Senior Helpline at 1-800-252-8966

OR, 111 E. Wacker Dr., Suite 1000 Chicago, IL 60601 (866) 454-3571

-Home Seniors

General:, 773-921-3200

-Will County Center for Community Concerns,, 815-722-0722 

-Alliance to End Homelessness in Suburban Cook County, 1-877-426-6515, 

Homeless Shelter Listing near Oak Lawn

Crisis Center for South Suburbia

Crisis Center for South Suburbia

Worth, IL 2.7 miles outside Oak Lawn, Illinois

To contact the Crisis Center 24 Hour Hotline dial 708-429-SAFE (7233).The Crisis Center for South Suburbia Residential Shelter program offers a safe haven for individu [...]

South Suburban - 2021

--CHF clinic:  708-213-3976

--Cardiac/Pulmonary Rehab: 708-213-3104

Wisconscin Accupuncture - AAH (8-9-2022)

Bay Care Clinic Pain & Rehab Medicine – Bay Park/Brown County at 2401 Holmgren Way,Green Bay, WI 54304 920-288-8377

Aurora Fertility Services/Kenosha County at6815 118th Avenue, Kenosha, WI 53209 262-857-5670

Aurora Health Center/Milwaukee County at 3003 West Good Hope Rd., Milwaukee, WI 53209 414-352-3100

Aurora Health Center/Milwaukee County at 6901 W Edgerton Ave, Greenfield, WI 53220 414-421-8400

Aurora Health Center/Milwaukee County at 1575 N Rivercenter Dr, Milwaukee, WI 53212 414-283-8444

Aurora Sinai Medical Center/Milwaukee County at Physical Medicine & Rehab (4th Floor, Easy Street) 945 North 12th Street, Milwaukee, WI 53201 414-219-5241

Aurora Women's Pavilion of Aurora West Allis Medical Center 8901 W. Lincoln Ave, West Allis, WI 53227 414-978-3000

Aurora Wiselives Center 8320 W. Bluemound Road, Suite 125 A, Wauwatosa, WI 53213 414-302-3800

Aurora BayCare Health Center/Outagamie County 1500 Arbor Way, Kaukauna, WI 54130 920-766-3200

Aurora Health Center/Washington County W180N11070 River Ln., Germantown, WI 53022 262-532-8400

Aurora Health Center/Waukesha County 16985 W. Bluemound Rd., Brookfield, WI 53005 262-641-8400

Aurora Health Center/Winnebago County 414 Doctors Court, Oshkosh, WI 54901 920-303-5100

WI Movement

Stepping Class


Caregiver or Patient Resources for Activities to Keep the Mind Healthy

AARP Word Games:

Alzheimer’s Society of Canada, BrainBooster Activities (including cross words, Sudoku, and word search):

Mather Telephone Topics: A variety of free classes, groups, and performances via phone - 

SeniorLink Blog: “Helpful Daily Activities for Dementia Patients: 50 Expert Tips and Suggestions to Keep Your Loved One Engaged” -

Senior Planet: Offers a range of online programs covering technology, fitness, and wellness -

TimeSlips Creativity Center: Ideas and prompts for creative engagement at home -

Well-Connected: A wide variety of free classes and groups for adults age 60+, available via phone or web - 

Memory Cafes, many of which are meeting virtually now:

North Shore Senior Center has been offering daily virtual activities for people with dementia:

Care Giver Resources for cases with Dementia

  • Join the Movement! Become a Dementia Friend
    • A Dementia Friend learns about dementia and then turns that understanding into action. We all have a part to play in creating dementia friendly communities! Please click here to learn more.

Resources for Providers

Self-Awareness and Self-Care Links

Take the Professional Quality of Life Scale: (5/22/2021)

Are you looking for an education and training center as a physician on wellness:, or (5/22/2021)

In need of mindfullness Medication: Spirit Rock Meditation Center at tttps://, or (5/22/2021)

Want to explore Poetic medicine: (5/22/2021)

Looking for the Now:, or join the AAH Narrative Medicine community that meets on a regular basis (5/22/2021)


How to send a letter to the Alzheimer's Association (AA) for them to reach out to the patient or caregiver

--Open a letter in Epic

--Select other templates

--Select Alzheimer's

--In template select if in IL or WI (will provide the correct AA Fax number)

--Complete the form-letter (requires verbal consent to fax to the AA)

--Fax the letter to the AA


Managers or Physicians that want to use the ACE Tracker;

Accessing an ACE Report

Access in Epic your Dashboard

Quality Clarity Report:  ACE Tracker QUA 1000

Quality Clarity Report: ACE Tracker Day Two Snaphot QUA 1065