Excelling Care Coordination

Excelling Care Coordination

CHS provides a comprehensive, holistic approach to care coordination and employs a multidisciplinary team in the provision of care.

CHS offers clients custom-tailored programs under the CHS umbrella of care for the Patient Centered Care Management (PCCM) model, with which CHS has over a decade of experience.

The Care Coordinators are integral to supporting and driving the improved health outcomes of CHS’ programs. To ensure that members are supported throughout the continuum of care, CHS finds that a mixture of roles is effective.

Care Coordinators may be Social Workers, Registered Nurses or Resource Navigators. Member Engagement Unit members may be Certified Nurse Assistants or experienced call center staff.


RN
  • Care coordinator for children with primary medical diagnosis
  • Assessment
  • Care plan development
  • Facilities and participates in care team meetings at MH as appropriate
  • Home visits as indicated
  • Education as indicated
Social Worker
  • Care coordinator for children with primary mental health or developmental diagnosis
  • Psychosocial assessment
  • Care plan development
  • Facilities and participates in care team meetings at MH as appropriate
  • Links family to community-based resources as indicated
  • Education as indicated
Resource Navigators
  • Follows up with and advocates for families to address any barriers to medication adherence, specialty care
  • Gathers school and clinical information
  • Assists in scheduling / verifying appointments and transportation
  • Calls family to remind them of upcoming appointments or need to set up appointment for preventive care or equipment maintenance
Member Engagement Unit
  • Initial introduction from the new health plan to the member
  • Educates on general plan information
  • Establishes member experiences
  • Responds to member questions
  • Completes the initial health risk screening
  • Assigns the member to a care coordinator depending on outcome of initial health risk screening