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Greater Lawrence Family Health Center |
Massachusetts |
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The Greater Lawrence Family Health Center has developed a pilot project that uses a multidisciplinary team-based model to systematically identify and reduce hospital admissions among super-utilizers. Care team members strive to address patients' medical, social and psychological needs through care coordination, navigation of social services, behavioral health integration and medication reconciliation. The model also provides wrap-around services to strengthen patients' relationships with primary care providers. This project is part of the Family Medicine Education Consortium (FMEC) Super-Utilizer Learning Community led by the Camden Coalition of Healthcare Providers. |
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Partner Organizations |
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Target Population |
Super-utilizers |
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Care Team |
Community health worker, preceptor, resident, nurse, medical assistant, behavioralist, clinical pharmacist, CCNC |
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Timeframe |
2016 - present |
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Results/ Studies |
N/A |
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Funding |
Provider |
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Resources |
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