Care Coordination

care coordination

Care Coordination is a service that helps adults and children with chronic illnesses get and manage the medical, social and community services they need to stay as healthy as possible.

“Care Coordinators” help clients figure out and take the actions that they need to take so they can get and stay healthy, like making it to important appointments, sticking to a medication schedule, and eating healthy foods. This helps avoid unnecessary hospitalizations by helping individuals deal with health problems with their doctors in the community before their issues send them to the hospital.

This service is for people who are 18 and older, have Medicaid, and may have asthma, diabetes, cardio-metabolic disorders, heart disease, HIV, hypertension, and mental illness.

How Care Coordination Works

  1. We learn about clients’ health needs and help them figure out which ones are being met and which ones are not.
  2. We help clients take action. We work with them to create care plans tailored to each person’s own health and social issues. With the help of the Care Coordinator, the care plan guides the client through the steps that will help them get and stay healthy
  3. We build a care team around each member. This team may be made up of several different people, like a primary care doctor, a psychiatrist, a social worker, and special doctors who treat things like diabetes or heart disease. The Care Coordinator brings all these people together to help the client set his/her health goals and support the member in reaching those goals.
  4. The Care Coordinator makes sure that all the systems are working together. That may mean ensuring specialists and your primary care doctor share information with each other, or creating links to community supports where needed, like Access-a-Ride or public assistance.

Types of Care Management

Blended Case Management Program

Matches client needs to community recreational, therapeutic, and academic supports.

Home-Based and Community Services Waiver Program

Intensive in-home case management services for youth including skill building, respite, crisis intervention, in-home sessions and case coordination.

Home-Based Crisis Intervention Program

A short-term intensive program to stabilize youth at risk for psychiatric re-hospitalization.

Caring Families Family-Based Treatment Program

Out-of-home placement for youth incapable of staying in there family home. Temporarily places children with families trained in behavior modification techniques.

The Family Resource Center

A parent-run, youth-oriented program for families with special needs children 0-24 years with an emphasis on its youth group for the transitional age range of 18 to 24 years.

Children’s Health Home

A care management program that will ensure the coordination of your child’s physical and behavioral health care needs by providing access to critical services that best meet their needs and support their wellbeing.