Care Coordination/Transition Support

Care Coordination provided by a certified LPN or MA to support patient panel management, including:

• Developing and maintaining disease registry
• Identifying patients in need of outreach to complete health screenings and close care gaps
• Daily monitoring of ENS alerts for hospital and ED discharges
• Providing monthly list of “high-risk” algorithm-identified patients for clinician review and risk stratification
• Telephonic outreach to enroll patients identified for care management
• Identifying potential patients for comprehensive medication management and advanced illness management
• Providing patient referrals to education and self-management resources, and community and social service resources
• Behavioral health relationship to establish and support collaborative care