Care Coordination

Care Coordination in the primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care outcomes.

What CC Nurses do:

• Provide routine calls or visits to see how you are doing.
• Provide medication education.
• Help improve your safety.
• Help arrange services to help you in your home.
• Help you make appointments.
• Give you information on resources available in your community.
• Help you if you have been in the hospital.
• Help schedule preventive screenings.
• Work with you to establish health goals.
• Provide education on your health conditions such as fall prevention, exercise, and nutrition.

CCHWs deal directly with social determinants of health, the non-medical issues that influence health outcomes. You do not need a provider referral or insurance to work with our CCHWs.

What CCHWs do:

• Helps obtain food and/or clothing.
• Conducts home visits to make sure home is safe and secure.
• Educates and supports patients after hospital stays.
• Provides help paying utility or medical bills.
• Connects with social services to help patients.
• and so much more.