Lancaster General Health's Care Connections Program

Pennsylvania

Lancaster General Health's Care Connections program utilizes interdisciplinary care teams to provide temporary, high-intensity transitional primary care to patients with multiple hospital readmissions resulting from complex medical and psychosocial needs. In addition to medical care, a county social service liaison helps patients find social services like housing, food and an appropriate insurance plan.

Partner Organizations

• Lancaster County Behavioral Health and Developmental Services
• LEMSA (Lancaster EMS)

Target Population

Adults with: 2+ medical conditions, multiple medication prescriptions, complex social needs or several visits to the hospital or ED in 6 months

Care Team

Physicians, advanced practice providers, patient care navigators, social workers/county social service liaisons, care management nurses, a behavioral health psychologist, a clinical pharmacist, a chaplain, a medical-legal attorney

Timeframe

2011 - present 

Results/ Studies

N/A

Funding

Medicare, Medicaid and private insurers

Resources

Program website