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Care Coordination provided by a certified LPN or MA to support patient panel management, including:
- Developing and maintaining disease registry
- Identifying patients in need of outreach to complete health screenings and close care gaps
- Daily monitoring of ENS alerts for hospital and ED discharges
- Providing monthly list of “high-risk” algorithm-identified patients for clinician review and risk stratification
- Telephonic outreach to enroll patients identified for care managementr
- Behavioral health relationship to establish and support collaborative care
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TRACK ONE Services
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Care coordination assistance with Track 2 requirements, including:
- Identifying potential patients for comprehensive medication management and advanced illness management
- Providing patient referrals to education and self-management resources, and community and social service resources
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