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Community Case Management

Community Case Management Referral Information

A service for people managing chronic illness.

The PVHS Community Case Management received the ANCC Magnet Prize. To learn more about this internationally recognized program, call 970.495.8554 or email

The PVHS Community Case Management Program helps at-risk families and individuals who don't have resources themselves, are chronically or terminally ill, and are not eligible for other in-home services. Community Case Management is a service provided by Poudre Valley Health System at no charge for those who qualify.

PVH Community Case Managers are Advanced Practice Nurses and Licensed Clinical Social Workers. The PVH Community Case Managers work with clients and their caregivers in their homes to help them cope with their disease or chronic health problems.

Consider referring individuals to PVHS Community Case Management if they meet the following criteria:

  • Customer of PVHS
  • Ineligibility for home care
  • Chronic conditions that have potential for complications (e.g., CHF, COPD, diabetes)
  • Confusion with medication management or treatments
  • Complex diagnoses needing additional education regarding their medical conditions
  • Frequent ER visits or hospitalizations
  • Poor coping skills
  • Inadequate family or support system
  • Caregivers who demonstrate high stress
  • Insufficient financial resources
  • Frequent missed appointments
  • Frequent visits for unnecessary problems

Community Case Managers include Advanced Practice Nurses and Social Workers who:

  • Provide a comprehensive client assessment in the home
  • Promote increased client competence and coping through treatment plans that include education and referral to other necessary resources
  • Provide periodic oversight of clients
  • Develop and strengthen support networks for the clients
  • Assist the client to utilize the health care system appropriately
  • Provide this service at no charge to clients who might otherwise not be eligible for other assistance

When you refer to Community Case Management, please provide:

  • Patient name
  • Patient birth date
  • Patient phone number
  • Brief statement of the problem

Contact us

PVHS Community Case Management
Phone: 970.495.8554
Fax: 970.495.7628

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