Care Connections is a community care team providing an innovative, intensive, and temporary primary care medical home for high-risk patients. We strive to meet the needs of individuals who have been admitted to the hospital multiple times because of a combination of behavioral health and three or more medical challenges.
A Comprehensive Approach
Care Connections integrates medical, behavioral health, and socioeconomic services. Our team-based approach helps connect the dots for patients with complex challenges, increasing their ability to manage their own health.
To transform the quality of care for patients with complex needs, by utilizing innovative delivery models and empowering each patient with sustainable skills and resources to self-manage care in his/her primary care setting.
Engagement: We commit to nurture the patient’s ability to solve problems through critical decision making, and strive to deepen the patient’s commitment to personal responsibility, community investment, partnership with a team, and personal wellness.
Quality Care: We define quality care as: holistic, patient-driven, empowerment focused, team-based, sustainably minded, engagement driven, multi-systemic and seamlessly transitioned.
Empowerment: We view the patient as the leader of a multidisciplinary team who will define and direct personal goals for health care empowerment. Motivational interviewing will provide the framework to identify patient goals and subsequently focus care team (including patient) on care management plan.
Sustainability: We will strive to create sustainable solutions to change that will equip patients with skills and resources for effective self-management of health care issues for the long-term.
Advocacy: We commit to advocating for individual needs of patients within the health care system, the local community and on state and federal levels. We also commit to advocating for new delivery models of care to help persons with complex needs and will strive to educate health care providers at all levels of training and experience.
In This Section...
Our Care Connections team that is made up of clinicians, social workers, case managers, patient care navigators, pharmacists, and chaplains.
A guide for Care Connections patients.
Learn more about our Population Health Fellowship and read a message from our fellowship director.