Care Coordination
Tammy Potter, a care manager at the Carthage Family Health Center, gives a hug to her patient, Debbie Platt, in September 2017.
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 Coordinators2019 Care CollaborativesTrainingsService Directories
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:
2019 Care Collaboratives
January
Jefferson/Lewis County:- Home Health — Jefferson County Public Health
St. Lawrence County:
- Home Health — Health Services of Northern New York
- Case Study — Transitional Living Services of NNY [Download PPT]
February
Jefferson/Lewis County:- Office for the Aging [Download PPT]
- ACO — HealthCare Partners of the North Country [Download PPT]
- Case Study on Care Management — North Country Family Health Center
St. Lawrence County:
FFF Details: This month’s care collaboratives focused on the Medicare population. Laura Yott and Joanna Loomis, from the HealthCare Partners of the North Country (HCPNC) Accountable Care Organization (ACO), presented on the ACO’s role in the community and Care Management Campaign. This campaign helps identify ACO Medicare beneficiaries who may benefit from care management services addressing their clinical and/or social needs. The ACO works closely with Primary Care Care Managers in reaching these beneficiaries.
Care Managers from Claxton-Hepburn Medical Center presented at the St. Lawrence County Collaborative on their processes, successes, and challenges they have encountered managing a patient’s care. These care managers play an essential role in hospitals and clinics for a great deal of care needs. Some of these needs include ensuring patients are getting the frequency of visits they require, their medications are accurate post-discharge, as well as maximizing the resources available to them utilizing community based organizations.
The Jefferson-Lewis County Care Collaborative welcomed Sheila Kehoe and Matt Wiley from Jefferson County Office for the Aging, who spoke about the services Office for the Aging offers the community and the Medicare population. Andrea Montgomery, Director of Office for the Aging St. Lawrence County presented on the services offered at the St. Lawrence County Collaborative. She provided the attendees with statistics for the elderly population in St. Lawrence County and the services they provide that population in their community. Some of the services provided by one or both of these two Offices for the Aging include:
- Legal Assistance
- Minor Home Modification
- Farmer Market Coupons
- Transportation Program information
- Expanded In-Home Services for the Elderly Program (EISEP)
- Health Insurance Information, Counseling, and Assistance Program (HIICAP)
- Medical Transportation via Volunteer Transportation Center, Inc.
- Computer Classes
Both Jefferson-Lewis and St. Lawrence County collaboratives had a great turnout with both collaboratives providing additional knowledge of another Community Based Organization they can utilize to help assist their patients in need.
March & April
Jefferson/Lewis County:- Federally Qualified Health Center — North Country Family Health Center [Download PPT]
St. Lawrence County:
- Federally Qualified Health Center — Community Health Center of the North Country [Download PPT]
FFF Details: March and April’s care collaboratives focused on our local Federally Qualified Health Centers (FQHCs). Felicia Parker, Population Health Program Manager at North Country Family Health Center presented at the Jefferson-Lewis County Care Collaborative and Ray Babowicz, Director of Communication, Government Relations, and Marketing at the Community Health Center of the North Country, presented at the St. Lawrence County Care Collaborative. Both presenters shared statistics from their Health Center with an approx. combined total of servicing 23,000 patients in our region in 2018. Some of the services provided by one or both of these two FQHC’s include:
- Dental
- Primary Care
- Pediatrics
- Telemedicine & MAT Services
- Behavioral Health
- Care Coordination
- School-Based Health
Both Jefferson-Lewis and St. Lawrence County collaboratives had a great turnout with both collaboratives providing additional knowledge on Federally Qualified Health Centers and the services that are available in the community for patient care.
To learn more about the services at the North Country Family Health Center, visit: https://www.nocofamilyhealth.org/
To learn more about the services available and locations of the Community Health Center of the North Country, visit: http://chcnorthcountry.org/
May
Jefferson/Lewis County:During the month of May, the Jefferson-Lewis County Care Collaborative welcomed Diane Kilburn from Samaritan Keep Home to introduce their Adult Day Health Care program. This program is a great benefit to the community as it offers several day care services for adults ages 18 and up. There are both full-time and part-time enrollment opportunities available and currently there is no waiting list. The program runs Monday through Friday, 9:00AM – 3:00PM and follows the school weather-related closures during the winter months. A few of the program services available include:
- Nutritional Meals – Continental breakfast, lunch and snacks
- Personal Care
- Health Care Monitoring
- Chaplain Available
- Therapy (speech, occupational, physical)
- Medication Management
- Social, recreational, and motivational activities may include: bingo, arts and crafts, wellness programs, etc. A group calendar is created each month.
Staffing for the program includes several different levels of clinical experience: RNs, LPNs, Social Workers, Dietitians, Therapists, etc. Accepted payers consist of Medicaid, Veteran Affairs, and private pay. To learn more about the program or obtain an application, please contact Diane Kilburn at 315-785-4492 or www.samaritanhealth.com.
St. Lawrence County:
June
Jefferson, Lewis and St. Lawrence Counties:- Population Health Program — North Country Prenatal/Perinatal Council [Download PPT]
FFF Details: Allison Roselle, Director of the Population Health Program at North Country Prenatal/Perinatal Council presented at both the Jefferson-Lewis County and St. Lawrence County Care Collaboratives during the month of June. The population health program offers services to adults 18 years of age and older that have been diagnosed with a chronic illness. Community Health Workers work in collaboration with the client to ultimately improve the quality of health independently while reducing emergency room visits, admissions, and re-admissions to the local area hospitals. Referrals to the population health program are not limited to only health care professionals, community referrals are also encouraged and accepted. This program services residents in the tri-county region — Jefferson, Lewis, and St. Lawrence counties.
North Country Prenatal/Perinatal Council offers programs for maternal and infant health, health insurance navigation, youth services, population health, and more. The referral form and more information can be located on their website at https://www.ncppc.org/.
Referrals for the Population Health Program can be emailed to referrals@ncppc.org or faxed to 315-222-7348.
Have questions?
For more information about Care Coordination in our region, contact Laura Yott.
