Care Coordination

CHS’ model for care coordination fosters productive interactions between informed members (who take an active part in their care) and providers with resources and expertise. The ultimate outcome is that healthier and more satisfied members lead to more satisfied providers and appreciable cost savings.

Excelling Care Coordination

Excelling Care Coordination

CHS provides a comprehensive, holistic approach to care coordination and employs a multidisciplinary team in the provision of care.

CHS’ model for care coordination fosters productive interactions between informed members (who take an active part in their care) and providers with resources and expertise. The ultimate outcome is that healthier and more satisfied members lead to more satisfied providers and appreciable cost savings.

RN

Care coordinator for children with primary medical diagnosis

Assessment

Care plan development

Facilitates and participates in care team meetings at MH as appropriate

Home visits as indicated

Education as indicated

Social Worker

Care coordinator for children with primary mental health or developmental diagnosis

Psychosocial assessment

Care plan development
Facilitates and participates in care team meetings at MH as appropriate

Links family to community-based resources as indicated

Education as indicated

Resource Navigators

Follows up with and advocates for families to address any barriers to medication adherence, specialty care

Gathers school and clinical information

Assists in scheduling/verifying appointments and transportation

Calls family to remind them of upcoming appointments or need to set up appointment for preventive care or equipment maintenance

Member Engagement Unit

Initial introduction from the new health plan to the member

Educates on general plan information

Establishes member experiences

Responds to member questions

Completes initial health risk screening

Assigns the member to a care coordinator depending on outcome of initial health risk screening