Administrative Services

Making a Positive Impact in Care Coordination

Doctor holding glasses and clipboard.

The Northeast PHO Care Management Team is proud to assist you and your patients with care coordination to improve quality and efficiency while working closely with the Northeast PHO providers. The Northeast PHO care management team provides case management outreach and support to the PHO high risk ACO population and Commercial population with BCBS, HPHC, Tufts and Fallon health plans. The Northeast PHO care management team consists of an experienced professional team.  Nurse Case Managers, Licensed Independent Social Workers, Patient Engagement Coordinator and a Case Management Assistant work in an integrated team model to better serve patients along the continuum of care. The team is also supported with assistance from our PHO pharmacist. The team provides transitional care, complex case management, disease management education, self-management education and community social service support to better serve the Northeast PHO providers, patients and families.

Integrated Team Model to Better Serve the PHO High Risk Population

Ambulatory Care Managers
  • Provide outreach to ACO high risk population to enroll in Care Management Program
  • Conduct face to face comprehensive geriatric assessment on high risk ACO population in the home or physician practice setting
  • Provide transitional care support along the continuum of care
  • Provide medication reconciliation assistance to patients and with referrals to pharmacist
  • Develop Care Guide and Action Plan with patient/caregiver and PCP
  • Utilize evidence-based tools for patient/caregiver education and coaching
  • Provide monthly monitoring calls to review Action Plan and progress toward goals
  • Utilize motivational interviewing to engage/support patient in self-management
  • Communicate and facilitate transfer of pertinent information at transitions of care
  • Serve as primary care manager support to PCP’s for ACO high risk population in the community
Transitional Care Manager – Acute
  • Provide transitional care support to targeted ACO population at home hospitals
  • Ensure face to face encounter with patient/caregiver to assess chronic care management and transition needs
  • Interface with multidisciplinary team to address patient concerns and facilitate referrals
  • Coordinate PCP follow-up appointment within 3-5 days of discharge to community
  • Provide transition call within 24-48 hrs of discharge to community to ensure safe plan and reconcile medications
  • Provide medication reconciliation assistance to patients and with referrals to pharmacist
  • Utilize evidence-based tools for patient/caregiver education and coaching
  • Serve as primary care manager support to PCP’s for ACO population in home hospitals
  • Provide social support assistance to patients with referral to geriatric social worker
  • Hand-off to PCP assigned ambulatory care manager to follow patient in community
More Info

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Q. Why do I have to check with my primary care physician (PCP) before seeing a specialist?

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Meet Sara Osman, MD

“Toby Wesselhoeft was a pioneer of the teaching of family medicine in this region, so I am truly honored to be given an award in his name, I am deeply passionate about the work I do and the students with whom I interact at Tufts University School of Medicine. This recognition is inspirational to me.”

− Dr. LaBarge

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Lorem ipsum dolor sit amet, consectetur adipiscing elit. Sed eros ante, dignissim sit amet pellentesque a, malesuada sed neque. Nulla elementum nisl ut odio aliquet

Dolor sit amet, consectetur adipiscing elit. Sed eros ante, dignissim sit amet pellentesque a, malesuada sed neque. Nulla elementum nisl ut odio aliquet

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