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    Here's how CPC+ benefits patients


    L.R. How often are social issues coming up and what are these issues?

    D.S. Social issues come up daily. These can include transportation needs and in-home needs. We have referred patients to local food pantries and directed patients to legal aid. We now have a behavioral health counselor embedded in our office one half day a week to help our patients deal with depression and anxiety. Personally, I feel that patients need more ‘soft touches’. The more we ‘touch’ them and check in on them, the more confident and in control of their own issues they feel. When a healthcare team can set goals and promote patient activation of those goals, it can increase a patient’s own health literacy. Social issues play a huge role in the overall health of a patient and need to be addressed.


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    L.R. From the interview, it certainly seems that working more closely with patients who have more need is very gratifying for the clinical staff involved. It also sounds like the CPC+ model may be able to make a difference for our sickest patients with hopefully less ED visits and less hospital admissions. Patients will need some re-education on the best way to handle their chronic illnesses and acute flares. As this occurs, it should make a vast difference in quality of care and improve the healthcare situation of our patients.  A win-win for all involved.


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