Координация ухода

What is Care Coordination?

Care coordination is when health care services and staff work together to organize provider visits and other services to make sure you get the best care. You, your family/supports, and your providers all work together to create a Person Centered Service Plan (PCSP) to meet your care needs. Your PCSP is made for you. It makes sure you have supports that know your language, your background, and your point of view. Your Care Coordinator will be one person that all of your providers can talk to. They can share information about your care needs. The Care Coordinator will make sure that the PCSP is being followed.

To reach a Care Coordinator:

Empower Healthcare Solutions (Empower) Care Coordination
CareCoordination@empowerhcs.com
Phone: 866-261-1286

Care Coordination Services

Care coordination will assist members with their healthcare needs by ensuring providers and services are working together so that the member’s health is improved. Care Coordinators will include members in development of the PCSP and provide choices for members in this process. Care Coordinators will also ensure compliance with the PCSP and will assist with any resources needed or barriers to accessing treatment.

Your Care Coordinator will also:

  • Teach you more about your health needs
  • Help with any needs in your day to day life, such as helping you eat healthy food and exercise
  • Work with providers that give medicine
  • Work with providers to coordinator care
  • Make a plan of care that has all your services listed
  • Help find you services
  • Help you find supports in your family and community
  • Help if you are in trouble or in crisis
  • Provide guidance and support
  • Help with paperwork
  • Monitor providers to ensure that services are provided in a safe and helpful manner
  • Ensure you have an assigned PCP
  • Ensure you regularly follow up for prevention, wellness, and sick visits
  • Ensure all members have active coverage
  • Will follow up with you within 7 days of an ER, Urgent Care, or Hospital Admission
  • Will contact the member to assist with discharge planning, prescription assistance, follow up appointment with PCP and Specialty Providers

Индивидуальный план обслуживания

Empower members have a PCSP. The Care Coordinator is responsible for obtaining copies of all treatment and service plans related to members and coordinating services between those plans. The goal is to prevent duplication of services, ensure timely access to all needed services, and identify any service gaps for the member, as well as provide any health education and health coaching identified by those plans. The Care Coordinator will ask members what goals they would like to achieve in addition to collecting the member’s treatment plans and ensuring follow up on those plans.

It is your right and responsibility to participate in the development of your PCSP by providing information, to the best of your ability, which Empower, or your provider may need to plan your treatment.

Your PCSP will include the following types of treatment or service plans:

  • Behavioral Health Treatment Plan
  • Person Centered Service Plan for Waiver Clients
  • Primary Care Physician Care Plan
  • Individualized Education Program
  • Individual Treatment Plans for developmental clients in day habilitation programs
  • Nutrition Plan
  • Housing Plan
  • Any existing Work Plan
  • Justice system-related plan
  • Child welfare plan
  • Medication Management Plan

Your PCSP will list what additional services are available to you. This may include:

  • Adult rehabilitative day service
  • Behavioral assistance
  • Child and youth support services
  • Family support partners
  • Medication counseling by registered nurse
  • Mobile crisis intervention
  • Partial hospitalization
  • Peer support
  • Recovery support partners (for substance abuse)
  • Residential community reintegration program
  • Respite, emergency and planned
  • Substance abuse detox (observational)
  • Supportive employment
  • Supportive housing
  • Supportive life skills development
  • Therapeutic communities
  • Therapeutic host homes

Your First Visit

At the first visit, you can expect the following from your Care Coordinator:

  • Introduction and Overview of Care Coordination
  • Contact Information for the Care Coordinator and Toll Free Number
  • Completion of the Healthcare Questionnaire
  • Discussion of Goals for Care Coordination
  • Obtain Release of Information for Providers and Support System
  • Healthcare Questionnaire which covers the following:
    • Current Health Status
    • PCP Information
    • Diagnosis
    • Medications
    • Провайдеры
    • Resources/Barriers to Care
    • Financial
    • Legal
    • Transportation
    • Cultural/Linguistic
    • Housing
    • Disabilities
    • Support System