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Care Connections

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Care Connections

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Care Connections FAQ’s


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Frequently Asked Questions for Patients

What is Care Connections?

Care Connections is LGH’s new PCP clinic for people who use a lot of hospital services and have social needs. 
 

Who are your patients?

Care Connection’s patients are adults (18 and older) with more than 2 medical conditions and who take a lot of medications. Our patients have gone to the emergency room or have been in the hospital a lot over the past 6 months. Our patients also have a lot of social needs. 
 

What is your program’s name?

The program is called Care Connections. Care Connections is a special primary care physician office. We help patients learn about their medical problems and help them to be well.
 

Are you part of a hospital system?

Yes, Care Connections is part of Lancaster General Health.
 

What are the types of providers and other staff on your team?  

Care Connections has a variety of staff to help patients in all areas of their health care. The staff include a pharmacist, doctors, nurses, a clinical counselor, a county social service worker, a chaplain, and patient care navigators.
 

What does the County Social Service Liaison do?

The county social service liaison helps patients find housing and food , they help find an appropriate insurance plan, and they work with other county agencies.
 

What does the Doctor or Nurse Practitioner do?

The doctor or nurse practitioner provides medical care.
 

What does the Clinical Counselor do?

The clinical counselor provides counseling and runs family and group meetings. 
 

What do Patient Care Navigators do?

Patient Care Navigators meet you at home or in the community to teach you about your health. Patient Care Navigators are available often and meet with you when you need them.
 

What does the Pharmacist do?

The pharmacist reviews your medications and help you organize them.  The pharmacist also monitors INR and Blood Pressure, and they can help adjust Coumadin or blood pressure medications.
 

What does the Nurse do?

The office nurse has a two jobs in Care Connections. The main job is to manage your care at all levels. The second job is to help with office visits, they help you get medical supplies, and they help with refills.
 

What does the Chaplain do?

The Chaplain meets with you about spiritual concerns you have.  They also give support.

 

How often does the team meet to review my care?

The Care Connections team meets daily to review your care.
 

Do you have formal partnerships with community groups? Which ones?

Yes we do. Care Connections works with Lancaster County Behavioral Health and Developmental Services and LEMSA. Care Connections has staff from these organizations on our team and we work together daily.
 

Do you have informal engagements with community groups?  

Care Connections works informally with any social service and health care providers in and around Lancaster County.
 

Why Is Care Connections needed instead of the home PCP?

Care Connections is able to spend more time with you during office visits. Care Connections can also be there for your urgent needs quickly with 24 hour on-call support.
 

How long is the patient in Care Connections?

Patients stay in Care Connections for a short time before they return to their home PCP.
 

What if a patient is concerned about losing their PCP?

Your referring PCP is never lost. Once you meet your treatment goals, you go back to your doctor.
 

What if the patient chooses not to enroll with Care Connections?

Care Connections is a voluntary program. You do not have to join if you do not want to.  
 

Where is Care Connections located?

Care Connections is located in Lancaster General Hospital. The office is on the first floor, near  the visitor elevators.
 

When is Care Connections open?

Care Connections is open Monday- Friday for office visits but an on-call representative is available 24/7. Patients can call anytime with concerns or questions. If a patient wants to go to the ER with a non-life threatening illness they are told to call the office first. Urgent appointments are often available. 
 

What, if any, group of patients do you exclude?

Care Connections does not work with patients who are currently being treated for Cancer at our Ann B Barshinger Cancer Institute, and those being treated for HIV at our Comprehensive Care Center office. Those centers have special care for those patients.
 

Where do you make first contact with me?

We try to meet you when you are in the hospital.  We may also meet you at home after a hospitalization.
 

How do you know I am ready to be discharged?

We know you are ready to be discharged when you meet your goals.
 

Do I sign anything to join?

Yes, you will sign a “Consent to Treat” form which tells you what will happen in the program. This form also tells us what you will do to be healthy.


How will you communicate with me? 

Care Connections will communicate with you however you would like. We use the phone, home visits, office visits, and the patient portal on-line.


How will you tell my PCP how I am doing?

We will talk with your PCP anytime there is something new they need to know about you. When you are ready to go back to them, we will also send a report to them about what you did when with us. We will also go with you to your hand back appointment to tell them how well you did in our program.


Will you talk with my specialty doctors?

Yes, Care Connections team members will talk with specialists as much as is needed to care for you.


Do you do home visits all of the time or sometimes?

We go on home visits as needed depending on your unique needs. Social Work, Patient Care Navigators, Chaplain, Pharmacy, and the providers can come to your home.
 

Is there one person who I always talk to? 

Patient Care Navigators are the best people to call first with questions but you can talk to anyone, at any time.


Can specialists and other caregivers reach a member of your team 24/7?

Yes, Care Connections office is open from 8:00 am -6:00 pm Monday – Friday. Care Connections has after hours on-call staff available if needed.
 

Frequently Asked Questions for PCPs

What is Care Connections?

Care Connections is LGH’s new PCP clinic for high utilizers of healthcare. This program assists patients who have been hospitalized 2 or more times in the last 6 months and who also have compounding psychosocial stressors to deal with. 


Who are your target populations?

Care Connection’s target population are adults (18 and older) with multiple complex medical conditions who are also on multiple medications. These individuals have been in the hospital more than 2 times within the past 6 months, and they have compounding psychosocial stressors which complicate their medical care.


How do I refer a patient?

Care Connections does not currently take referrals for our program.  Care Connections has a data model to identify patients.  When patients meet our criteria, we reach out directly to them to enroll them in our program.
 

What is your program’s name?

The program is called Care Connections. Care Connections specializes in primary care for individuals with a lot of social and medical concerns. They focus on organizing all patient care, including; medications, personal needs such as housing, transportation, and relationship development and maintenance.


Are you affiliated with a hospital system?

Yes, Care Connections is affiliated with Lancaster General Health.


Are you affiliated with a FQHC (Federally Qualified Health Center)

No, we are not affiliated with a FQHC. Care Connections does however collaborate on care with FQHC physicians who have patients currently in our program.


What are the types of providers and other staff on your team?  

Care Connections has a variety of staff to help patients in all areas of their health care. The staff include a pharmacist, doctors, a nurses, a social worker, a county social service worker, chaplains, and patient care navigators.


What does the county social service liaison do?

The county social service liaison assists patients with finding housing and food , they help find an appropriate insurance plan, and they coordinate with other county agencies.
 

What does the Chaplain do?

The Chaplain helps the patient with any spiritual concerns they may have.  They also give support.


What does the doctor or nurse practitioner do?

The doctor or nurse practitioner provides medical care.


What does the Clinical Counselor do?

The clinical counselor provides counseling to interested patients and facilitates family and group meetings.  They also assist with the completion of Advanced Directives. 


What do Patient Care Navigators do?

Patient Care Navigators meet the patient at home or in the community to teach patients about their health, to coach patients on taking care of themselves, and to help patients figure out what is needed to be healthy. Patient Care Navigators are available often and interact with patients as needed, often a few times a week, or when ordered by our providers, they can help with health care education, and they can help with blood sugar monitoring.


What does the Pharmacist do?

The pharmacist reviews and evaluates the patient’s medication from all prescribing doctors/providers. The pharmacist works with each patient to come up with organized methods for taking their medications. The pharmacist also monitors INR, Blood Pressure, and they can help adjust Coumadin or blood pressure medications.


What does the Nurse do?

The office nurse has a dual role in Care Connections. The main duties include managing care throughout all levels of service for the patient. They also assist with office visits, they keep in touch with the patient’s home PCP office, help obtain medical supplies, and help with refills. At time of discharge, our nurse coordinates care with case managers.


How often does the team meet to review cases?

The Care Connections team meets daily to review patients. These daily huddles review new patients, patients who have been hospitalized, and patients who will be seen that day.


Do you have formal partnerships with community groups? Which ones?

Yes we do. Care Connections believes in collaborating with all providers who are touching the lives of our patients. Formal partnerships include our collaboration with Lancaster County BHDS and LEMSA. Care Connections has imbedded representatives from these organizations directly into our team and we work together daily.


Do you have informal engagements with community groups?  

Care Connections has informal partnerships with a variety of social service and health care providers in and around Lancaster County.


Why Is Care Connections needed instead of the home PCP?

While many doctors would like larger amounts of time to meet patients, we recognize that current models of healthcare often do not allow for these extended visits. Care Connections allots more time for direct patient care. In a highly coordinated environment, Care Connections can respond to the patient’s acute needs quickly with 24 hour on-call support.


How long is the patient in Care Connections?

Patients stay in Care Connections for a short time before they return to their home PCP.  Length of enrollment varies between 6-9 months depending on the needs of each individual patient.


What if a patient is concerned about losing their PCP?

The referring PCP is not lost by the patient. Once the patient meets their Care Connections treatment goals, they return to their home PCP for continued care. Efforts are made to communicate to the PCP the goals achieved while the patient was in the care of Care Connections.


What if the patient chooses not to enroll with Care Connections?

Care Connections is a voluntary program. Patients do not have an obligation to enroll, though it is highly encouraged based on hospital usage.


Where is Care Connections located?

Care Connections is conveniently located within Lancaster General Hospital. The office is located on the first floor, adjacent to the visitor elevators.


When is Care Connections open?

Care Connections is open Monday- Friday for office visits but an on-call representative is available 24/7. Patients can call anytime with concerns or questions. If a patient wants to go to the ER with a non-life threatening illness they are instructed to call the office first, as acute appointments are often available. 


What are the sources of funding for your program? 

Care Connections is funded by billing patient’s insurance.


Is your program a PCMH or do you plan to become PCMH certified?

Care Connections is not currently a PCMH.


Is your program affiliated with a family medicine residency program?

Yes, Care Connections currently has a Fellow on staff, as well as a rotation for residents within our program. 


What, if any, group of patients do you exclude?

Care Connections excludes patients who are currently being treated for Cancer at our Ann B Barshinger Cancer Institute, and those being treated for HIV at our Comprehensive Care Center office.


How do you identify potential participants?

Participants are identified through a data model which collects information on diagnosis, prescriptions, barriers to care, and utilization.


Where do you make first contact with a patient?

Initial patient contact is made while the patient is currently in the hospital.  If the patient is discharged before we are able to connect with them, we will meet them in their home.


How do you assess “readiness for change”?

Care connections providers use a tool that identifies if a patient is ready for discharge. The tool reviews the patient goals as well as progress on those goals. 


Do you have patients sign a care agreement?

Care Connections patients sign a “Consent to Treat” form which outlines expectations for patients’ participation in the program. Care Connections also requires patients to sign a contract allowing for proper communication between patient and team members.


What are different methods you use to communicate with patients? 

Care Connections communicates with patients by their preference. We use the phone, home visits, office visits, and patient portal.


How do you interact with the patient’s PCP?

Care Connections interacts with the home PCP as needed for patient care. Collaboration occurs heavily at the start of care before enrollment to understand the patient’s history, and then at time of graduation when we hand the patient back to their PCP and recount the treatment received. If needed, providers will contact the home PCP during treatment as well for clarifications.


Do you interact with patients’ specialist physicians?

Yes, Care Connections team members will interact with specialists as much as is needed to care for the patient. Patient Navigators can also attend specialty appointments with patients for continuity of care.


Do you do home visits routinely or just as needed?  What types of staff do the home visits?

Care Connections team members, chaplains, the Clinical Counselor perform home visits as needed. Social Work, Patient Care Navigators, Pharmacy , and the providers can go to the home to provide needed care. We can also provide care in the community if the patient prefers it.


Is there a single contact person from your team for the patient? 

Patient Care Navigators are best suited for being the point person for the patient’s care.  However, the patient can contact any team member at any time.


Can specialists and other caregivers reach a member of your team 24/7?

Yes, Care Connections office is open from 8:00 am -6:00 pm Monday – Friday. Care Connections has after hours on-call staff available if needed.


Do you have a shared care plan that you establish with your patients?

Yes. As part of the medical record, each patient has a treatment plan which incorporates medical goals as well as psychosocial goals. Other providers may learn of the treatment plan by obtaining the appropriate releases of information.


What are the criteria for “graduating” from your program?

Graduation occurs when patients have met or exceeded at least 50% of their goals, and the patient is believed to be able to be managed with the case management structure of their home PCP.  

 
 





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