Community Care Coordination
Community-based care coordination is a partnership among health care professionals, mental health professionals, pharmacists, clinics and hospitals, specialists, community services, and others working together to provide person-centered, coordinated care. Whether in the context of an integrated health partnership, accountable communities for health, patient-centered medical home, health care home, or other structure, the goals are similar: Continually improve health care quality and patient experience while reducing overall costs.
Our coordinators are trained to advocate for and liaise between the target population and a variety of health, human, and social services organizations. They passionately support individuals by: Providing information on health and community resources
In building and expanding a community-based care coordination program, our agency supports the community by:
Providing active management of transitions-in-care and tracking of referrals to help ensure a closed loop of information
Providing funds to ensure that the individual has essential items when transitioning to the community
Engaging with community partners as an integral part of a holistic approach to patient care
Transforming care delivery from provider-centric, episodic care to patient-centered and community-based health and wellness
Reducing the burden on providers by supporting patients in actively managing their health conditions through patient engagement and education