A comprehensive, physician-directed approach
Our Continuing Care program is physician-directed, serving as an extension of the primary care physician's practice. Once the patient is referred (or self-refers), the patient, care coordinators and physicians work together to assess and meet the patient's needs.
How the program works
The Continuing Care Program is staffed by highly trained care coordinators. These nurses, social workers and assistants work closely with high-risk and rising-risk patients to promote better management of their health by:
- Developing personalized goals and self-management improvement strategies for patients.
- Helping patients manage and attend their appointments.
- Assessing medication schedules, potential medication risks and patient educational needs.
- Educating patients to better understand their situation and their treatment plan.
- Identifying social and clinical challenges that may lead to avoidable hospital visits.
- Coordinating a transition of care plan between hospitals and outpatient care.
- Assessing behavioral health challenges, including substance use disorder and other mental health issues, and assisting patients with
getting the care they need.