Caring for Our Population and Care Coordination
Here at Westchester Health, we’re committed to delivering the highest level of compassionate, highly personalized medical care, centered around you and your family. With an integrated team of physicians, nurses, nurse practitioners, physician assistants, care coordinators and clinical consultants, all working together for your best possible health outcome, you can be confident that you are receiving the expert, patient-centered care you need and expect.
A focus on our population’s health
At the same time that we are thoroughly committed to your personal care and helping you manage your condition, we are also highly focused on the health of the population we serve. For this reason, we offer additional services to support our population-based care initiatives.
Comprehensive care coordination: a collaborative team partnering with you
As part of our personalized approach to our patients’ health and well-being, we assign a care manager to oversee the care of patients with chronic diseases such as diabetes, coronary artery disease, COPD, arthritis, osteoporosis, dementia and cancer.
This healthcare professional works closely with your primary care provider and other specialists to implement a total treatment plan customized for your specific condition in order to achieve the best possible outcome. In addition, your care manager helps you better understand your condition and your doctor’s personalized care plan for you.
At Westchester Health, our care managers:
- Meet with your physician(s) to understand all details about your condition and care plan
- Make sure you have the support and education you need to better understand your condition and care plan
- Work with you, your family and your caregivers to make sure you have the right information, skills and tools to achieve self-management of your care
- Encourage you to ask questions about your care, now and for the future
- Facilitate communication between your providers
- Help with referrals
- Work with you to make appointments and coordinate transportation
- Enter data on your condition so that your providers and our population health registry can track how you are doing
- Increase patient satisfaction
- Conduct regular reviews of your progress and make sure every member of your care team is informed and up-to-date
- Monitor your medications and help you manage them
- Make sure that needed treatments and services are not duplicated or unintentionally overlooked
- Connect you with community resources, as needed
- Track your status when you obtain services outside of the Westchester Health network
- Follow up with you within a few days of an Emergency Room visit or hospital discharge
- Become an important resource when you are discharged from the hospital to your home, a rehab center or a nursing home
- Greatly improve the quality of care you receive
- Increase patient satisfaction
Transitions of Care: Ensuring a smooth transition from the hospital
The goal of our Transitions of Care team is to make sure you receive the best possible follow-up care after you are discharged from the hospital, nursing home, rehabilitation hospital or emergency room. Our team works closely with these medical facilities to ensure that your transition to home goes smoothly.
First, we are notified when you are admitted to the hospital. Then once you are home, we follow up with a phone call. During this call, a nurse will ask how you are doing and if you need help with anything. He/she will make sure your medications are updated in our electronic health record and that you have a follow-up appointment with your primary care doctor. Next, our transitions of care team will review your hospitalization with our care managers and will refer you to a care manager if you could benefit from care coordination.
Westchester Health is your Medical Home
A Medical Home is not a building, a house or a hospital. Rather, it’s an approach to providing continuous, comprehensive primary medical care that is accessible, family-centered, coordinated, compassionate and culturally effective.
In each of our patient-centered, team-based Medical Home offices, a primary care physician works in partnership with the patient and his/her family to make sure all of the patient’s medical and non-medical needs are met, with the goal of achieving maximum health outcomes for each patient, from infants to older adults.
At Westchester Health, we are very proud that we have been recognized by the NCQA (National Committee for Quality Assurance) as a Level III Patient-Centered Medical Home —the highest accreditation possible—for demonstrating better patient experience, better health and lower per capita cost.
Medical Home benefits
Our Medical Home model improves care through a coordinated team effort led by your primary care physician. When Westchester Health is your Medical Home, we get to know you well so that we can care for you as a whole person, not just in terms of your condition. We call this continuous care.
Continuous care is possible through an ongoing relationship with your primary care physician who leads a dedicated medical team including specialists, therapists, case managers, nurses, hospitals and even non-Westchester Health entities. Most of all, we want you to feel well-cared-for and in control with a more coordinated, more efficient and more personalized approach.
Communication: you talk, we listen
We encourage you to tell us about your family, your life situation, your likes and dislikes. Ask us questions and we will give you clear, concise answers. With this input, we will be better able to discuss what treatment options are best for you.
In the same way, your doctors also talk and listen to each other. Using the latest technology, Westchester Health physicians can quickly, clearly and privately share your medical records, track test results, monitor your condition and decide on the best treatment.
You click. We respond.
Once you register with our patient portal, you will be able to receive reminders, track test results, renew prescriptions, manage bills, read visit summaries and connect with a care manager. Also, a Westchester Health physician is always available to you, and we provide same-day appointments when needed.
We call this: All Access. All Day. Every Day.
Make Westchester Health your Medical Home
To register, go to the Westchester Health secure patient portal and select a primary care physician for 24/7 access to your information and services.
Please call us with any questions you have about your care coordinator, our Medical Home program or our population health initiatives.
Hester Beukes, MSML, CHC
Director of Quality and Performance Improvement
Our Transitions of Care team