Case manager/Social Worker
Jessica Dwyer 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
Jessica 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
Christina Stoker, NBC-HWC, National Board Certified Health and Well-being Coach
MACIPA’s National Board Certified Health and Wellness Coach works directly with motivated patients to make behavior and lifestyle changes to improve their health. They help patients recognize and move through their personal barriers, as well as help build self-efficacy by setting achievable goals to create sustainable, healthy lifestyles.
The coaching program guides patients through the process of developing a detailed Wellness Vision – a compelling statement of who they are and what health-promoting, life-giving behaviors they want to do consistently. Next, patients develop 3-month goals that support their vision and weekly goals to get them moving forward. The program is tailored to the patient’s specific needs and can last anywhere from 3 months to 1 year.
Conditions that are appropriate for health coaching include Hypertension, Diabetes, Obesity, and tobacco/substance use. Health coaching is available for patients with the following insurance plans below and is provided at no cost to the patient.
- Medicare ACO
- Tufts Medicare Preferred
- Tufts HMO
- BCBS HMO/PPO
- Harvard Pilgrim HMO
- Cigna HMO