Many types of patients can benefit from Care Coordination, which strives to meet the comprehensive medical, behavioral health and psychosocial needs of each individual patient while promoting high-quality care and cost effective outcomes.
To help you care for complex patients, the Care Coordination team is taking a proactive approach, reviewing daily reports on high utilizers and high-risk patients — in particular, patients with three or more ED visits in a six-month period, patients who are readmitted within 30 days, any hospital admissions and those with certain chronic diseases as their chief complaint(s).
In these cases, the team screens to determine the patient’s need for Care Coordination, reviewing the patient’s medical chart as well as available information on their social determinants of health. They will reach out to the patient — with communication to the primary care physician as well — to explain the Care Coordination program and invite them to enroll.
Patients may also self-refer to the program, and as a physician, you may recommend that they enroll in Care Coordination. To refer a patient, simply call (209) 956-4422.
Better Understand Care Coordination
You can find the Care Coordination Toolkit and additional information on the secure Provider Portal under Network Highlights. These materials will help you and your staff better understand the services provided by Care Coordination and their importance in improving patient health and satisfaction.
Plus, be sure to send patients to the SJQCN website to learn more as well.
To refer a patient to Care Coordination, call (209) 956-4422.