A Unique Physician-Directed Approach

Unlike many traditional care coordination models, our Ambulatory Care Coordination program is physician-directed, which means that it serves as an extension of your own care practices. Once you refer a patient to the program, you will consistently stay informed of their progress and will be involved in decision making related to their treatment. This includes face-to-face meetings within your practice as well as the sharing of care plans, outreach reports and documentation of a patient’s progress.

How the Program Works

The Care Coordination Program is staffed by highly-trained care coordinators. These registered nurses have access to a wide variety of resources, which may include other clinical and social support professionals. Ongoing patient outreach may be conducted in-person and/or by telephone.

Our care coordinators work closely with high-risk and rising-risk patients to promote better management of their health by:

• Developing personalized goals and self-management improvement strategies for patients.
• Helping patients maintain their regular appointments.
• Assessing medication adherence, potential medication risks and patient educational needs.
• Educating patients to better understand their situation and their treatment plan.
• Identifying social and clinical challenges faced by the patient that lead to avoidable hospital visits
• Coordinating a transition of care plans between hospitals and outpatient providers
• Assessing behavioral health challenges such as substance abuse and mental health issues and helping patients get the right help.

A Care Coordination Success Story

David* is a 66-year-old diagnosed with Type 2 diabetes in 2014, with an A1c of 8.5. He is also morbidly obese. Shortly after diagnosis, David was referred to care coordination for in-person and telephonic support. The care coordinator provided education and an action plan to help him adopt healthy eating habits and increase his activity level. Seven months later, David has lost 65 pounds, his A1c is 5.8 and he no longer needs to take medication to manage diabetes and high blood pressure.

*Patient name has been changed to protect privacy.