For Catawba Valley Medical Group (CVMG), the top priority of our providers
and staff is helping you and your loved ones prevent illness and maintain
physical and emotional well-being by providing medical care and recommending
healthy lifestyle choices. We truly believe that your family medicine
provider should be your first line of defense in guarding your most valuable
possession of all:
your health. And to help us better serve our patients, we utilize the Advanced Care
Team Model in each of our 17 practices.
What is an Advanced Care Team?
An advanced care team is a group of people who support your primary care
physician in their efforts to deliver effective patient centered care.
This team is made up of:
- Social Worker (LCSW)
- RN Health Navigator (RN)
- Pulmonary Health Navigator (RT)
- Patient Care Advocate (CMA) & Administrative Care Coordinator
How does an Advanced Care Team Model work?
The goal for this model of care is to improve patient outcomes by optimizing
care coordination and ensuring each patient follows through with their
prescribed care plan. This means taking into account factors in a patient’s
life, outside of their illness, that impact the successful implementation
of a plan of care. Things such as transportation, financial assistance,
medication assistance, transitional care management after discharge from
hospitals and skilled nursing facilities, etc.
For example:A CVMG RN Health Navigator conducted telephone outreach to a patient for routine
follow-up. She was familiar with the patient’s health conditions
and communication pattern from previous interactions. Through her interactions,
she identified the patient had altered mental status. EMS was activated,
and the patient was admitted, evaluated and treated. RN Health Navigator
also assisted in coordinating placement arrangements, so the patient could
live more closely to family members.
Our Advanced Care Team Model in Action:
CVMG’s advanced care team members spend their time establishing close
relationships with patients, providing education and support, connecting
patients with resources, coordinating care, and communicating and collaborating
with providers. Below are just a few examples of how utilizing a care
team model has resulted in successful outcomes for our patients:
- A patient with multiple chronic diseases used the emergency department
and inpatient services frequently over the past year due to complex health
conditions. Our RN Health Navigator established a relationship with the
patient as part of transitional care management outreach. Through ongoing
telephone communication, she coordinated multiple resources and services.
As a result of continued care management support, the patient is now involved
in disease-specific education and community programs, the complex health
conditions have improved, all while emergency department visits for non-emergent
care and inpatient admissions have decreased.
- A patient needed testing for a pulmonary condition but could not afford
the services. The Care Coordinator worked with the specialty provider
office as well as the insurance company to help the patient obtain the
- A patient was discharged from the hospital with an extensive wound but
was unable to change dressings. Home Health had been ordered but the patient
had no way to care for herself in the interim. The RN Health Navigator
worked directly with Home Health to communicate the urgent situation and
expedite next-day initiation of home health services.
Finding a provider that can cater to the health and wellness needs of your
entire family can be difficult, but through the Catawba Valley Medical
Group you can find a number of skilled providers experienced in treating
patients of all ages.
Visit us online to learn more about each of our family medicine practices and to find
a location convenient for you.