Activities are conducted by care coordinators to address barriers, incorporating medical and behavioral health providers treatment plans and specialist in the community, creating a service plan to accommodate patients needs.
Coordinating appropriate linkages, referrals, and follow-up on medication, laboratory, medical recommendations, will help close service gaps that fall through the cracks. Care coordination promotes integration, team support, education, connecting with service providers to reinforce treatment strategies that support patients overall wellbeing. It helps understand self-management of one’s health conditions.
Care Coordinators’ activities include, but are not limited to:
- Outreach and engagement of patients.
- Ongoing communication with patients, their family, prescribers, and team members, conducting follow up care to address health and safety concerns.
- Educating to have access to pharmacology, age-appropriate resiliency, and recovery support services, and natural and community supports.
- Assisting the medical and psychiatric team in crisis interventions, follow up treatment plans.
- Incorporating Life's Skills services are integrated for individual support as identified in the Service Plan.
- Collaborating with primary, specialty, transitional health care from the Emergency Department, acute facilities, group homes, long term care facilities or rehabilitation centers.
- Assisting in referrals by educating on the importance of compliance and conducting follow-up monitoring.
- Connecting patients to understanding of self-management plans.
- Delivering health education to patients’ chronic conditions, medical concerns
- Conducting a face-to-face in-home visit.
- Coordinating with the MCO care coordinators to achieve connection to reducing barriers