Care support resources

How Legacy supports population health

Legacy Health’s care support resources provide personalized support to help you care for patients who need the most help to
reach their health goals.
Meet your care support resources team.

Laura Cirotski, BSN, R.N. Kim Pasic, BSN, R.N. Chip Pascu,
Care manager Care manager PharmD, BCACP
Pharmacist
lcirots@lhs.org kipasic@lhs.org
cpascu@lhs.org
503-415-4748 503-415-4742
503-415-4741

Jamie Dieter, BSN, R.N. Janine Richardson, Nathaniel Thompson-

Care manager BSN, R.N., CCM Moore, PharmD, BCPS
Care manager Pharmacist
jadiete@lhs.org
503-415-4702 janarich@lhs.org nrthomps@lhs.org
503-415-4743 503-415-4749

Christy Eib, BSN, R.N. Jason Hodges, Kelli Unzicker,

Care manager M.S., B.S., CHWC LCSW, LICSW
Health coach Clinical social worker
cmeib@lhs.org
jahodge@lhs.org kunzicke@lhs.org
503-415-4703
503-415-4747 503-415-4746

Laura Hagen, R.N. Brian DeGiovanni, CPhT Amanda Schmidt

Care manager Pharmacy technician Patient-centered
medical home program
Llhagen@lhs.org bdegiova@lhs.org
coordinator
503-415-4745 503-415-4704
aschmidt@lhs.org
503-415-5108

Jill Jacobson-Smith, Kathy Nguyen, PharmD (continued)

BSN, R.N. Pharmacist
Care manager kanguye@lhs.org
jmjacobs@lhs.org 503-415-4701
503-415-4744
Team roles
Care manager
Care managers serve two important roles for our
patients: they help with the transition from hospital
to home and with the intensive case management
services for identified complex patients. The role
of transition care is to ensure a safe and seamless
transition for the patient from hospital to home, and
to reduce the possibility of a hospital readmission
or emergency room visit within the first 30 days of
discharge.
Patients who need continued care after the transition,
or more complex care management, are assigned
a care manager who works collaboratively with
the patient’s primary care provider to develop a
patient-centered care plan to improve health. The
care manager identifies any gaps in care or barriers
to attaining services, as well as coordinates care by
serving as a contact point, advocate and resource for
the patient, providers and anyone else they identify
as being involved in the patient’s care.
Health coach
Health coaching is a patient-centered approach to
delivering care that assists individuals in achieving
wellness goals. Through periodic phone calls, health
coaches help patients build the knowledge, skills and
confidence required to manage chronic conditions
and improve their health. Specific support services
include teaching disease-specific skills such as blood
glucose monitoring, agenda planning for clinical
visits, connecting patients with resources, and
functioning as a cultural bridge or point of access for
patients, among others.
Legacy Health
For more information on care support resources:
503-415-5557
phso@lhs.org
Pharmacist
Our clinical pharmacists are skilled in medication
management for patients with complex disease states.
These pharmacists work closely with patients to
promote an understanding of medication use and
health, focusing on the evaluation and improvement
of medication-related problems. They collaborate
with providers to optimize patients’ pharmacotherapy
to help meet their treatment goals for diseases like
diabetes, hypertension, hyperlipidemia, depression,
COPD and others. The pharmacist can also be a
medication information resource for patients and
providers.
Social worker
The social worker provides social work services
to patients identified as needing ancillary mental
health/psychosocial services. The social worker
receives referrals from and works collaboratively
with the care support resources team. Some of the
key services are psychosocial assessment, problem-
solving counseling, crisis management, access to
medications and referrals to insurance, referrals to
community resources and education.
Medical home program coordinator
The role of the medical home program coordinator
is to share best practices and provide at-the-elbow
support to assist in implementation and process
improvement related to this model of care. The
coordinator is well versed in the requirements for
both Oregon and national patient-centered medical
home certification and is able to provide certification
guidance and education to your site.
MAC-4838 ©2015