At CCG we do this by utilizing Population Health Nurse Care Managers. These managers offer behind-the-scenes expertise on the areas of our patients’ lives beyond the symptoms that brought them into care.
On one level, this becomes highly individualized. Personalized goals identify other areas that impact the person’s overall wellness – housing, legal aid, job skills, and so on. On another level, we look at the data and identify trends in our patient population to lift up all of our patients at once.
Here’s how that piece can work
Each month we will focus on one or more healthcare indicators, based on areas of high risk for our community. Then we tailor approaches for the entire treatment team to address. This may be specific educational components, referrals for supportive services, or in-depth, one-on-one assessment to guide additional treatment.
In this way, the care becomes proactive and preventative. We don’t wait for emergency hospitalization. We look for indicators that might precede a crisis, and add supports to ward it off.
Many of our patients find this approach more successful. They aren’t treated as a certain set of conditions, but as a whole person with complex and overlapping needs. Diet and exercise become paramount, as do social supports, income, and meaningful activity. These are the things that sustain wellness.
We promote self-management and empower our patients. We outfit them with the information and resources they need to better manage the multiple factors in their lives. Self-management can have a dramatic effect on out-of-office disease treatment.
We accept Medicaid, Medicare and Self-Pay patients.
An important component of integrating mental health and substance use treatment
