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Care Connections has shown encouraging
outcomes in its first five years. Patients' inpatient stays have decreased 55 percent (when
comparing one year prior to enrollment to one
year after enrollment). Likewise, emergency
department visits have decreased 33 percent.
The total costs of care have dropped an average of 57 percent, from nearly $38 million to
$16 million.
The program is open to patients who are seen
by Lancaster Health Center (formerly Southeast
Lancaster Health Services), have an LG Health
Physicians primary-care provider, or have no
primary-care provider. Care Connections is an
integral part of the accountable care strategy for
high-risk care management, as part of the LG
Health Community Care Collaborative. To be
eligible, patients must have been hospitalized
at least twice in the past six months and have
two or more comorbidities. They usually face
additional risks due to social factors, such as
limited access to housing, transportation,
food, and legal services. Often they also have
behavioral health conditions and/or substance
abuse issues.

Care Connections
integrates medical,
behavioral-health, and
socioeconomic services in
a team-based approach
designed to support
care coordination and
patient engagement.
Patients meet with their care team,
including a clinical pharmacist, care
management nurse, county social service
liaison, medical-legal attorney, financial
counselor, chaplain, patient care navigator, and behavioral health professionals to
review medical and other issues. They also
set goals. Patients' personal goals vary from
walking to the mailbox without shortness

of breath to seeing a child graduate from
high school.
The Care Connections team helps patients
understand that good health is more than the
absence of disease or injury, and it strives to
empower them to shape all of the elements
that contribute to a sense of positive identity,
self-worth, and hope. These include physical
health, mental health, work, social interactions,
living conditions, and spiritual development.
Care Connections offers a range of
expertise and support to meet each patient's
individual needs. For example, many of the
program's patients take 20 to 30 medications, which are frequently changing. In
many cases, literacy, vision, or cognitive
issues impact individuals' ability to take
medications correctly. To help alleviate
that problem, patient care navigators visit
patients at home for hands-on medication
Other team members help patients address
social challenges that directly impact health,
which can make even scheduling and keeping
an appointment difficult. Care Connections'
attorney helps patients navigate income,
housing, employment, and other legal issues.
Also, a financial counselor works with patients
to develop a budget and address credit issues,
and a chaplain guides patients in advance
care planning.
Patients who meet their goals "graduate"
from Care Connections and return to their
original primary-care physicians. Many patients
are enrolled for about six to nine months, until
their medical conditions stabilize and they learn
how to navigate the health care system and be
accountable for their own care.
Because Care Connections is a short-term
provider, it also connects patients with community resources to continue their success after
graduation. Patients might be referred to an
LG Health Ambulatory Collaborative Care
Team to increase continuity of care during
the transition period.

So far 262 patients (66 percent of those who
enroll) graduate from Care Connections and
return to their original primary-care practice.
The success of the program has brought
significant savings for the Medicare and
Medicaid programs and LG Health. But the
real victories are in the patients' stories, such
as that of "Jose" (not his real name).
When Jose, a 46-year-old Hispanic man,
joined the program pilot in 2010, he weighed
475 pounds. He also suffered from poor
circulation, chronic obstructive pulmonary
disease, asthma, kidney disease, chronic pain,
hypertension, and depression. Leg ulcers frequently landed Jose in the hospital and posed
the risk of amputation. His dream of returning
to sound health seemed impossible to him.
Jose enrolled in Care Connections at the
recommendation of his trusted family physician. Once Jose's new medical-legal attorney
helped him access the full Social Security
benefits for which he was eligible, he could
afford the medications he needed. His care
navigator helped him access health insurance
for the first time. As a result, Jose was able to
have bariatric surgery, after which he lost 130
pounds. As his weight dropped, his leg ulcers
began to heal.
Counseling provided through Care Connections helped to diminish Jose's depression. He
gained confidence in his ability to control his
own health, and his life improved dramatically.
Jose's team believed in him and treated him
as an individual with the potential to change
the world around him.
Eventually, Jose graduated from Care Connections and began to volunteer in LG Health's
physical therapy department, encouraging
patients who, like himself, were ready to give
up hope. Today he acts as a patient partner
in Care Connections, helping to refine the
services offered to patients.
Jose is a prime example of how Care Connections' comprehensive team approach empowers
patients to reach their highest potential.

FOR MORE INFORMATION ABOUT CARE CONNECTIONS, contact Cindy Kuzma at 717.544.2273.





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