Our care team includes:
Registered Nurse: Ascension Saint Agnes Community Health Partners Care Transformation Organization utilizes a triad model consisting of a registered nurse, social worker, and care coordinator to individualize the care plan based on the needs of each patient. We are able to work with practices to customize care management to support their needs.
Social Worker: The Social Worker provides assessment and care coordination for patients with safety concerns, mental health conditions, substance use and housing insecurity.
Care Coordinator: The Care Coordinator connects patients with community resources to address financial strain, food insecurity, transportation, insurance needs, and access to care.
Our experience has reinforced that where possible, in-person care management, instead of primarily telephonic engagements, can better serve some segments of our population. A detailed risk-stratification that combines both medical complexity and an ongoing assessment of social determinants of health allows our teams to meet our patients’ needs with agility and compassion. Providing complex care management for high-need, high-cost patient populations not only improves patient outcomes, but can also have a financial impact.
The care management team offers two types of care management:
Longitudinal Care Management: Supports patients’ ability to manage chronic conditions and complex medical needs.
Episodic Care Management: Supports patients for a fixed period of time, often focusing on supporting patients after hospital discharge to ensure they understand any new medication regimens, attend follow up appointments, and aid in reducing readmissions.
Behavioral Health Integration
In addition to traditional care management, embedding behavioral health within primary care settings is a necessary step in providing patient-centric care. Our CTO can advise on best practices to integrate behavioral health within the primary care setting and implement preventative screenings for substance abuse and mental health. Our licensed social workers support patients through talk therapy, development of individualized care plans for behavioral health treatment, and referrals to treatment providers.
