Care Coordination

Chronic Disease Care Coordination

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We help patients to make sense of all thier health records and care plans from their multiple providers. We aim to reduce the complexity for the patient through ongoing support, reviewing any changes, and ensuring the patient understands what those changes mean to their overall care-plan.  

Post-Hospital Discharge Support

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Research shows patients only understand about 50% of their discharge instructions once they get home. Our care team  serves as a resource to answer any questions that may come up to keep patients on the right track. 

Mental Health Support

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We help pateints coordinate thier mental health needs. We can also help providers follow-up with patients at risk for opioid addiction by acting as an extention of their care team and support to the patient.

Social Determinants of Health

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We help providers identify their patients' social determinants of health such as housing needs, lack of  insurance and unemployment  and help the patient connect with resources to address them. 

Patient Education Workshops

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We help providers and healthcare systems identify their patients that would benefit from certain health education sessions. We coordinate them and conduct them, so their patients get the information to improve their health, the opportunity to ask questions in a relaxed environment, and the ability to be more engaged in their care.