“Putting the Patient First” means we have to meet the patient where they are at the time they need us most and having the right team with the right clinical skills assures our patients we have the ability to do so. Our Care Management Team consists of Registered Nurses (RN), Licensed Practical Nurses (LPN), Licensed Masters Social Workers (LMSW) and Community Health Workers (CHW) to serve our patients needs throughout their lives.
The Team
RN Care Manager Program
Providing the best quality care to every patient is our primary goal. The only way we can meet this goal is to work together. This is possible through our Nurse Care Manager Program. Genesys PHO has a team of Registered Nurses working directly with your doctor as part of his or her team to assist educating you on your disease process and how you can manage it and increase or maintain the lifestyle you desire. The RNs will work with your doctor to assist with disease or pre- disease conditions such as:
- High Blood Pressure
- Diabetes
- High Cholesterol
- Weight Loss
- Smoking Cessation
- Kidney Disease
- Heart Failure
- Asthma
- COPD
- Link to Community Resources
As part of the program, we have RN Care Managers at Ascension Genesys Hospital to meet patients, admitted for Heart Failure or COPD, at their bedside to provide education, assure you are ready for discharge and to help you schedule follow up appointments with your doctors.
RN Care Managers help through EDUCATION, MOTIVATION, & SUPPORT!
LPN Transitional Care Program
These nurses will meet you while you are in a skilled nursing facility after a hospital stay. They will provide education you will need when you go home to assure you can self-manage your disease and also assure you have resources needed when you get there. They may refer you to an RN Care Manager to follow you once home.
LMSW - Social Work Program
We have Licensed Social Workers who will work in collaboration with your doctor to assist you with community resources if necessary as well as Behavioral Health issues. We understand that illness, whether a new diagnosis or a chronic condition, can lead to anxiety and/or depression and our social workers can help.
Community Health Worker Program
Managed by the leader of our Nurse Care Manager Team, the Community Health Worker is dedicated to strengthening the relationship between the primary care office and the patient by contacting patients after an emergency department visit and assist in arranging follow up appointments with their doctor as well as discussing any additional resources the patient may need. The CHWs may refer patients to the RN Care Managers or LMSWs as well.
Community Paramedic Program
This program is currently only open to patients who have recently been admitted to Ascension Genesys Hospital with a diagnosis of Congestive Heart Failure or Chronic Obstructive Pulmonary Disease. Paramedics perform health assessments, medication reconciliation and reviews discharge care plan with patient within 48 hours of discharge. After or during the Paramedic visit with the patient, the Paramedic will be in contact with your doctor. Interventions may be done if needed in your home to prevent you from having to return to the hospital.
Collaborative Care Management (CoCM)
We know that behavioral health is just as important as your physical health. Many people don’t have access to behavioral health care. Collaborative Care Management (CoCM) is a program that provides behavioral health care through your PCP office while working with a Behavioral Health Care LMSW and consultation between your PCP and a Psychiatrist.
Your Health Your Choice
Advance Care Planning Program
One of the most important choices facing you is your choice for future medical care. Advance Care Planning is a process for you to understand possible future health care choices; reflect on those choices in light of the values and goals important to you; discuss your choices with those close to you and your healthcare professionals; and make a plan for future healthcare situations.
Begin now and take the time you need to understand, reflect, discuss and make a plan for future healthcare decisions that will work best for you and those closest to you.
We are happy to answer your questions and assist you in reviewing and completing your Advance Directive. For additional information on Advance Care Planning or to schedule an appointment with a Certified Advance Care Planning Facilitator, please click on the link below or contact us at (810) 424-2270.
This is a FREE program offered throughout Genesee County and the surrounding areas.
https://gfhc.org/advance-care-planning-your-health-your-choice/
Ask your doctor about your eligibility to enroll in these programs or give us a call at: (810) 424-2000