Care Coordination
If you are a Cone Health patient in need of care coordination, disease management and education, or if you need help with other barriers to meeting health goals, we are proud to offer our Care Coordination program. Chronic Care Management (CCM) and Care Coordination services are offered through the extension of care teams.
Through Care Coordination at your Cone Health primary care physician’s practice, you can get support specific to your needs that extend beyond exceptional routine office care you already receive.
The Care Coordination team is made up of the following team members:
- Registered Nurse Care Guide: disease management, health education, care coordination and complex case management
- Clinical Social Work: Complex Care Coordination including coordination of level of care needs, mental and behavioral health assessment and recommendations, and connection to long-term mental health support
- Clinical Pharmacist: medication management, assistance and disease management
- Clinical Pharmacy Assistant: provides support and assistance to pharmacist with patient care needs
- Community Resource Care Guides: community resource connections
- Scheduling Team: dedicated team of scheduling professionals to support patient and clinical team scheduling needs
Extension of care at Cone Health utilizes a patient-centered care model to put together a multi-disciplinary team to meet the needs of each individual patient.
Who is a good fit for Care Coordination?
Care Coordination teams are uniquely positioned to address a broad variety of patient care needs. A few examples are:
- Education and disease management support for patients with a new diagnosis such as hypertension, hyperlipidemia, diabetes, or even a rare disease
- Assessment, recommendations, and long-term community connections for patients with needs related to unstable or poorly controlled mental or behavioral health
- Research, coordination, and support for patients with mobility barriers in need of equipment coordination or patients in need of connection to long term food or transportation resources
- Help being matched with a senior center or day program in the geographical area of seniors with a disability or who are in need of socialization and/or activities
- Information about connections to programs like Silver Sneakers or other exercise or nutrition programs in the geographical area of patients with who are interested in improving their health or have been recommended to start exercise and nutrition programs
Care Coordination services are available to any patient whose medical home is a Cone Health Medical Group practice. If you are receiving Chronic Care Management services, your health plan is directly billed, and most plans have a $0 copay. If you are eligible for standard Care Coordination, there is no cost to you.
Contact Us
Do you have questions about how Care Coordination at Cone Health works, or whether you’d be a good fit? Ask your doctor or other health care provider about it today, or contact us at (336) 832-8760 for more information about this program.
