Care Coordination

Our care coordination team is proactive and comprehensive - addressing patient needs across the outpatient, emergency, inpatient and post-hospital discharge settings. Seamless communication and documentation tools, standardized workflows and close relationships help us improve quality, patient experience, efficiency and as a byproduct, total cost of care.

The hallmarks of care coordination are:

  • sharing and implementation of best practices across the care continuum
  • reduction of waste and duplication of services
  • use of technology to support workflow, communication, innovation and future growth

Team-based Care is Better for Patients

For patients who have multiple chronic medical conditions or frequent hospitalizations, a care coordinator on their team is a game-changer. The care coordinator increases “touch points” of care between visits, whether in person or by phone. The care coordinator serves as a health coach, not only helping patients navigate a complicated medical system, but also motivating them toward reaching their health care goals.

Our care coordination model is "nurse-led" and includes nurse care coordinators, care coordinator assistants, a social worker, a certified diabetes educator, health coordinators and post-acute care partners. Our diverse team meets the needs of the entire person by focusing on clinical, psychosocial, transitional care, care gap closure, and wellness promotion.

Patient Education

Educating, discussing strategies and answering questions enables the patient to self-manage their condition. Empowering the patient to partner with us in their care is what makes the care coordination program effective.

 

patients who have multiple chronic medical conditions or frequent hospitalizations. Having a care coordinator in a practice is a game- changer. It’s all about increasing “touch points” of care between visits, whether in person or on the phone.

Outpatient Care diagram