Care Management & Family Consultation (RN-Led)
About this service
An RN Care Manager serves as your family’s single point of coordination—assessing needs, building a measurable care plan, aligning public programs with private services, and keeping everyone (family, providers, and funders) on the same page. In Alberta, publicly funded home care begins with an AHS case manager assessment; when CDHCI is chosen, AHS authorizes the service types and hours and approved hours are billed directly to Alberta Blue Cross. We complement that system by coordinating with your family doctor’s Patient’s Medical Home (team-based primary care) and by navigating equipment supports through AADL (authorizers + approved vendors), all while protecting health information under Alberta’s Health Information Act (HIA)
Who it's for
- Families with complex or changing needs (multi-condition seniors, recovery after hospitalization, dementia, palliative) who need a clear plan and one accountable lead.
- Clients using CDHCI who want help blending authorized hours with private add-ons (e.g., transport, extra nursing) and documenting changes for the AHS case manager.
- Anyone who would benefit from tighter primary-care coordination (appointments, results, medication changes) in line with the Patient’s Medical Home model of care coordination across the “health neighborhood.”
What´s included in the service?
RN assessment & measurable plan
Review risks, goals, meds, and home setup; set outcomes and review dates; align with the AHS plan (and CDHCI authorization, if applicable).
Care team orchestration
Coordinate with your family doctor/PMH, community programs, pharmacy, and rehab; book/sequence services to avoid duplication and delays.
CDHCI navigation
Clarify what AHS has authorized (personal care, essential health-linked homemaking, in-home respite), track usage, and document change requests; ensure approved hours are billed via Alberta Blue Cross.
Equipment & supplies (AADL) coordination
Arrange authorizer assessments and choose from approved vendors/product lists; explain eligibility and cost-sharing
Family meetings & education
Arrange authorizer assessments and choose from approved vendors/product lists; explain eligibility and cost-sharing
Privacy & consent management
Obtain consents, share the minimum necessary information, and store documents consistent with Alberta’s HIA.
Frequently asked questions
How does this differ from the AHS case manager?
AHS case managers determine eligibility and authorize public services; our RN Care Manager supplements that role by coordinating day-to-day execution across public and private pieces (e.g., CDHCI hours + private nursing + transport) and by keeping your PMH team in the loop.
Can you help us apply for or adjust CDHCI hours?
Yes. We prepare clear summaries for the AHS case manager when needs change (e.g., new wound care, caregiver burnout). Approved CDHCI hours are then direct-billed to Alberta Blue Cross by the provider you choose.
What if we need equipment (walker, commode, lift, bed)?
We’ll connect you with an AADL authorizer and help select items from approved product lists and vendors; AADL outlines eligibility and cost-share rules and requires use of approved vendors.
How do you protect our health information?
We follow Alberta’s HIA—collecting/using only what’s necessary, documenting consent, and sharing information with your care team under the Act’s rules (with limited, specific circumstances for disclosure).
Why involve our family physician?
The Patient’s Medical Home vision places your family practice at the centre of coordination; we share concise updates and care plans so primary care can adjust medications, referrals, and follow-up efficiently.
Download our guide
Check out our guide to Home and Community Care.