As our increasingly complex healthcare system continues to evolve and grow, our patients are receiving care and interacting with a number of physicians, nurses, case managers and other healthcare professionals across multiple settings. As a result, we’ve learned that healthcare providers must coordinate with each other to ensure the patient gets what they deserve — the right care at the right time and by the right person.
Care coordination is a system in which teams of healthcare professionals work together to ensure all of their patients’ health needs are being met. It encourages communication, collaboration and information sharing among healthcare providers and utilizes care coordinators to help patients who may need additional help.
Care coordinators are trusted advocates who go above and beyond to assist with a patient’s medication questions, transportation issues, insurance coverage, referrals, housing, and much more.
Looking toward the future, as healthcare delivery moves away from a “fee-for-service” model and is replaced with “value-based care,” healthcare professionals are focusing more on the outcomes of patient care — and care coordination is at the center of this shift.
Since care coordination is a crucial part of improving our region’s health and reducing fragmentation within the healthcare delivery system, NCI is committed to creating an effective and sustainable care management platform across Jefferson, Lewis and St. Lawrence counties.
This page is dedicated to providing valuable resources for our region’s care coordinators. If there is anything you’d like to see added, please get in touch with NCI’s Care Coordination team!
Resources for Care Coordinators
- What is Care Coordination? — An overview of care coordination, values and principles of a care coordinator, and the key functions of a care coordinator.
- What is the Health Home? — The Health Home is not a place; it’s a team-based care model. Click to learn more.
- Members of the Care Team — Care Coordination requires the insight and collaboration of several different medical specialists. Click below to learn more about some of the members of our region’s Care Team.
- Referral Forms — Do you know someone who could benefit from Care Coordination services? Browse the following referral forms to get started:
- Alzheimer’s Association of Central New York (direct connect referral form)
- Maximizing Independent Living Choices (universal referral form)
- North Country Health Home (referrals for children’s programs)
- North Country Prenatal/Perinatal Council (referrals for Community Health Worker Program)
- Northern Regional Center for Independent Living (universal referral form)
- Samaritan Home Health (universal referral form)
- St. Lawrence County Mental Health Clinic (referrals for adults)
- St. Lawrence County Mental Health Clinic (referrals for children)
- St. Lawrence County SPOA Committee (referrals for adults)
- St. Lawrence County SPOA Committee (referrals for children)
- St. Lawrence Psychiatric Center (referrals for Mobile Integration Team)
- Please fax completed form to Angela Burke at 315-541-2041.
- Transitional Living Services of NNY (universal referral form)
Care Coordination Collaborative Materials
- Presentations from our most recent meeting —
- “SPOA — St. Lawrence County Resources”
- “Disease Specific Care Management: Congestive Heart Failure”
- Click here to watch a video of the presentation!
- “Community Health Workers and Chronic Conditions”
- “The Growing Need for Population Health Management: Steps to Improving Diabetes Outcomes”
- NCI Community Support Service Directory
- North Country Prenatal/Perinatal Council Directory of Community Services
- 2-1-1 Central New York
- CMS Chronic Care Management Resource
- Behavioral Health Providers Directory