Interdisciplinary team
Interdisciplinary teamwork is the foundation of effective primary care. As an OhioHealth Graduate Medical Education practice, our patients receive the support of a collaborative Care Management team. This team consists of a Care Manager (RN), a Social Worker, a Community Health Worker, and a Financial Counselor. This team to support patients with multiple comorbid/chronic conditions, assesses for social determinants of health, and links patients to resources.
In addition, we are supported by an in-house pharmacist who functions under Collaborative Practice Agreements (CPAs) in Diabetes, Hypertension and Hyperlipidemia. The collaboration between our physicians and pharmacist, allows our team to best serve our patients in managing their chronic conditions between visits.
Team members:
Andrew Faiella PharmD, BCACP: Pharmacist
Tori Avina-Heinl, MA, IMFT-S: Director of Behavioral Sciences
Tracy Johnson, RN, BSN: Nurse Care Manager
Emma Johnson, MSW, LSW: Social Worker
Kaitlyn Morrisey: Community Health Worker
Brent Lake: Financial Counselor
Goals of the Care Management Team:
Extension of primary care team to help patients navigate the health care system
Coordinate care across continuum
Provide comprehensive, holistic assessments to identify barriers to care
Develop support and trusting relationships with patients
Engage patients in treatment plan and guide to self-management
Key services from the team:
Transition of Care
Management of a panel of patients who are high risk for hospitalizations
Support for patients with high utilization of the emergency department
Disease-based management and education
Linkage to community resources to address social determinants of health
Support patients in meeting health goals