Healthcare can be stressful and confusing to patients, especially when they have chronic diseases and complex health needs. Our specially trained nurse care coordinators work closely with primary care physicians to coordinate the care of these high-risk patients, help them navigate the healthcare system and solve complex issues.
Our nurses meet with these patients at their physician’s office as well as over the phone to obtain important information prior to or during their visit with the physician. They check medications and doses, ensuring the patients are taking their medications as prescribed and receiving refills. After the physician discusses goals for disease management, the nurse coordinator follows up to ensure compliance or assist with removing barriers.
Using the power of our clinically integrated network and advanced technology tools, we assess risk acuity. This allows our experienced staff to focus on the right patients at the right time, provide support when it’s needed most. The goal is to help patients manage their disease, while reducing hospital admissions and Emergency Department visits.
We provide assistance with:
- Helping patients understand their health conditions and treatment options
- Providing educational materials and resources as needed
- Identifying needs and goals of patients and their families in managing chronic diseases such as diabetes, COPD, hypertension, chronic kidney disease, and heart disease
- Reviewing medication lists
- Coaching in lifestyle issues, such as healthier eating and smoking cessation
- Assisting patients with transportation and medication needs
- Facilitating access and referrals to social and community resources, including mental and behavioral health resources
our Physician Engagement team to learn how you can add care coordination to your Primary Care practice.