Care Coordination through Chronic Care Management keeps the focus on you and what is best for reaching your care plan goals mutually developed by you, your provider and others involved in your care.
Care Coordination has been proven to improve patient health, reduce costly ER visits and prevent hospitalizations.
Need additional support and don't know where to turn? Your Care Coordinator will work with you to ensure you get the resources and follow-up care you need and deserve.
A Better Healthcare Experience For You
Care Coordination provides resources to help you and your family to:
- Understand your medical condition, treatment options and treatment plan (especially important if multiple treatment plans are prepared by different specialists)
- Identify your treatment goals
- Review medications to ensure the proper drugs are taken at the right time
- Connect with medical professionals and community support resources (e.g., Diabetes Educator)
- Receive the follow-up care and regular attention you need to avoid setbacks and achieve your health goals
Check-ins and appointments with your Care Coordinator will be done primarily by phone offering you the convenience of visits from the comfort of your own home.
What Is a Care Coordinator?
A Care Coordinator is an experienced and specially trained Registered Nurse who assists in the management of complex and chronic conditions. They are Certified Health Coaches who advocate for the patient and serve as a point of contact when working with your care team to ensure you have what you need to reach your health goals mutually determined by you, your family and your providers.
Transition and Follow-Up Care
For many patients, being discharged from the hospital means they are "on their own" for getting the right follow-up care or ongoing treatment—but you don't need to feel alone! Your Care Coordinator will work with you, your doctor and hospital staff to evaluate your options and help you get the care you need.
Care Plan Review and Coordination
Complicated conditions often involve treatments from several specialists who may not always communicate about a patient's care. Your Care Coordinator supports your primary care provider, who is like the quarterback of your healthcare team, sharing the treatment "game plan" and making sure you, your family and all of your providers stay in the loop.
It can be overwhelming to keep track of different medications, especially if you have prescriptions from multiple specialists. Your Care Coordinator will gladly review your full list of medications and supplements with you to help develop a plan to ensure the proper drugs are taken at the right time. They will also work with your providers and pharmacists to help you avoid dangerous interactions.
Who Qualifies for Care Coordination Services?
Individuals who have both Medicare Part B and two or more chronic health conditions are eligible for Care Coordination Services. Patients with a Medicare Advantage Plan through a private insurance company may be eligible for Care Coordination Services.
How Do I Sign Up?
If you are interested in Care Coordination to help understand and manage your care, please speak with your primary care provider about a referral. A referral must be placed by a primary care provider before services can begin.
meet our cfvh care coordinator
View Shelby Zenahlik, BSN, RN, CFVH Care Coordinator profile.
Learn more about CFVH care coordination
View our CFVH Care Coordination Video for more details about our program.