title: Redesign links CMs, primary care.
abstract: At WellSpan Health, teams that include hospital-based case managers and social workers, and health coaches located in physician offices, work together to coordinate care. The case managers and social workers are assigned by physician and spend most of their time in the hospital, but are expected to spend a target of two hours a week at the WellSpan Medical Group physician practices. Practices that are not part of the WellSpan Medical Group are assigned a case manager and a social worker who follow their patients in the hospital but do not visit the practice. The initiative promotes communication and collaboration between the hospital level of care and primary care.
mesh_terms: D000553:Ambulatory Care / Q000458:organization & administration*; D019090:Case Management / Q000458:organization & administration*; D014487:Centers for Medicare and Medicaid Services, U.S. / Q000458:organization & administration* / Q000592:standards; D003266:Continuity of Patient Care / Q000458:organization & administration; D006760:Hospitalization; D006801:Humans; D033183:Interdisciplinary Communication; D017146:Models, Organizational; D018802:Patient-Centered Care / Q000458:organization & administration*; D010414:Pennsylvania; D012947:Social Work / Q000458:organization & administration*; D014481:United States; D000078329:Workforce