About Community Care Network

Continuing Your Care at Home

The Community Care Network (CCN) was developed to help patients coordinate their healthcare after they get home from the hospital. You'll have a team of professionals – social workers, registered nurses (RNs), RN case managers, pharmacists, diabetes educators, dieticians, home health nurses and others – to help you navigate your path to improved health. Dedicated clinical and medical directors will oversee your needs to make sure the team supports your goals and your physicians' plan of care.

How Does It Start?

While you're at Marshall Hospital, you'll get a visit from either CCN Clinical Director Penny Lehrman, BSRN; Medical Director William Klas, MD; or other CCN team members. They will assess your health history. They will listen to you. They will get to know you and your needs, all the while explaining the Community Care Network. When you decide to participate (the program is voluntary), they will work with you to determine your goals for your health and help you develop path to get there.

Who Can Participate?

Those identified as being at high risk for readmission due to chronic disease can participate. The CCN will receive referrals from an RN Case Manager or healthcare provider.

How Does It Work?

We'll assemble a team that will be part of your care and recovery. This team will be your support system.

If you need help with meal planning, you'll have a dietitian by your side to help you create a healthy eating plan. We may even take a trip to the grocery store with you. If you want to start a home exercise program, we can map a walking route near your home or go with you to the gym. If you have difficulty getting to medical appointments, we can plan a way to help get you there.

How Much Does It Cost?

There is no cost to participate in the CCN program. The program is voluntary and is open to all people regardless of insurance status.

How Long Is the Program?

There is no set timeframe for participation. You will receive care as long as it is beneficial to you.

For more information abut the CCN, call Marshall Medical Center at (530) 622-1441.