Care Coordinator - Family HealthCare Networks : Job Details

Support patient centered, continuous and consistent care, ensuring that an assigned Home Health Program (HHP) patient receives access to needed services identified through the assessment process. Coordinating, maintaining and servicing panels of patients with special service needs, as determined by the Health Home Program and stratification process. Working with the patient to implement their Health Action Plan (HAP). Assisting the patient in navigating health, behavioral health, and social services systems, including housing and transportation. Sharing options with the patient for accessing care and providing information regarding care planning. Identifying barriers to the patients treatment. Monitoring and supporting treatment adherence (including medication management). Assisting in attainment of the patients goals as described in the HAP. Encouraging the patients decision making and continued participation in HHP. Accompanying patients to appointments as needed. Monitoring refe...Care Coordinator, Coordinator, Transportation, Clinical, Support, Management, Healthcare