Case manager/Social Worker

Lee Machado Dunham RN is a nurse case manager that works along with the physicians to meet the complex needs of patients with multiple chronic conditions. These include:

  • Comprehensive assessment with patients and/or caregivers regarding medical and social issues
  • Disease management
  • Safety and home management

Lee develops a plan of care with the doctor to address the concerns that are putting a patient at risk for injury, hospitalization or exacerbation of an illness. The nurse case manager keeps the physicians informed of how their patients are doing between doctor visits. She follows through with implementation of the plan by working closely with patients and physicians and others to provide coordinated patient centered care.

Two members of the MACIPA Social Work Department work at Reservoir Medical.

Laura Klein, MSW, LCSW, provides social work case management services. She works to address the psychosocial needs of patients, which have a high impact on disease management. She provides our clinicians with a fuller picture of the patient-at-home and increases the ability of the clinician to fine tune the patient’s care, help maintain patients at home and increase patient satisfaction. She is available to meet with patients and families. Her functions include:

  • In Office and Home Visits
  • Support to Caregivers and Families
  • Making Referral to Therapists and Support Groups
  • Helping resolve complicated situations such as Isolation, Stress or Safety
  • Helping Seniors and Families with Life Span Planning
  • Connecting patients with Community Resources and Elder Services

Skaina Germain, Health Coach, works with patients who struggle to manage:

  • Diabetes
  • Cardiovascular disease
  • Hypertension
  • COPD

She helps and supports patients to set achievable goals in order to lead a healthier, more active and satisfying life. Skaina meets patients in the office or in their homes and then continues to work with them over the phone. She helps patient identify their strengths and harness them to make positive changes which directly impact their chronic disease management.

Skaina is currently facilitating a pilot Mobile App program at Reservoir Medical Assoc..