Often times, patients may be unaware of the team of Case Management staff at Health Access Network and Penobscot Valley Hospital who work behind the scenes to ensure their patients are receiving the best possible plan of care.
Case Management is a team approach to healthcare. Members of that team may include the patients, their families and friends, physicians, case managers, and other caregivers. As part of this healthcare team, HAN and PVH are able to help patients and their families understand and cope with medical, psychological, social and practical concerns related to their illness and treatment.
Upon admission into Penobscot Valley Hospital, most patients consent to sending medical updates to their primary care physician (PCP) of choice. For patients with a PCP practicing at Health Access Network, the PVH Case Management Department works together with staff at HAN to provide the best possible care for the patient.
For example, Case Management staff at HAN and PVH are in communication with each other throughout the day discussing specific patient concerns including immunizations, medications, lab and test results, scheduling follow-up visits, home health care service options, and much more. At the time the patient is discharged from PVH, HAN Case Manager, Kathy Bishop, RN receives a discharge summary. Kathy places a caring call to the patient 24 to 48 hours after discharge to discuss any after care that may be needed.
Another area that PVH and HAN are collaborating is in regards to Emergency Department use. PVH sends HAN discharge information for patients seen in the emergency room. Calls are placed to these patients and any follow-up appointments are made, medication checks are completed, and if needed, wound care is scheduled.
PVH Social Worker Mike Corbin describes HAN as, “Very amenable to work with and helpful in getting patients’ needs met quickly. Together, we work in the best interest of the patients and help to prevent readmission to the hospital after discharge.” |