Care Coordination

Care management services focus on coordinating the care and services needed by patients with complex issues through the continuum of care. Care Coordination is individualized to accommodate a patient’s needs with collaboration with the patient’s physician(s). Palos Health Care Coordinators are nurses who outreach to patients via telephone. There is no charge to patients or physicians for care coordination services.

 

Examples of services provided by care coordinators:

  • Providing ongoing patient and caregiver education
  • Scheduling physician appointments
  • Performing medication reconciliation after hospital discharge
  • Identifying barriers to care and connecting patients with needed resources
  • Reviewing health maintenance and  closing care gaps
  • Setting patient-specific goals
  • Reviewing plan of care in EPIC and maintaining complete care management notes in EPIC to assist physicians
  • Assisting with care planning services for patients with chronic, progressive illnesses (including coordination of palliative care and hospice service to optimize quality of life)

Examples of appropriate referrals for potential Care Coordination:

Patients with the following high-risk medical conditions may be referred by their primary care physician or specialty care provider for a care management services evaluation:

  • Multiple chronic conditions or uncontrolled illness (e.g. uncontrolled asthma, diabetes, etc.)
  • Member accessing ER services frequently/unnecessarily, etc.
  • Cancer diagnosis
  • Trouble with medication adherence, transportation to appointments, or picking up medications

Care Coordinators can be reached by calling 708.827.CARE. Referrals can also be made through EPIC Hyperspace or Palos Link. See the instructional video on this page to learn how.

Video: How to Refer to Care Coordination using Hyperspace or Palos Link

Practice Resources for Patients