Program or Project:
Care Coordination & Navigation
Percentage of time over term member will spend with this program:
The member will support the Care Coordination Nurse in coordinating non-medical needs for high risk patients (transportation, appointment scheduling). The member will conduct outreach to patients using ER departments for non-urgent conditions in order to redirect back to the health center for primary care services- this could include the identification of barriers to health center utilization vs. emergency room utilization. Assist highest-risk patients (based on their literacy, age, diagnoses, or housing status) in navigating/attending appointments with specialists and/or outpatient studies or community-based programs (such as tobacco cessation, nutrition, or other resources).
The member will conduct outreach to 10 – 12 patients a week regarding non-urgent ER utilization, and schedule primary/preventative care appointments when applicable; Remind patients of other methods of access to providers.