TEAM - BASED - CARE
Patient Care Coordination and Case Management
Team Based Care
Introduction:
Team Care Purpose
Team Care Functions
Focused Care Clinic
Our Team Care involves Patient Care Coordinators (PCC) who utilize case management and care gap coordination, supporting patients with acute and chronic conditions within our Patient Services Center, including:
Gather information to ensure healthcare services are organized, timely and prioritized.
Verify the benefits and eligibility of members when care coordination or case management requests are made.
Help patients with scheduling appointments, arranging transportation, and connecting them with available community resources.
Participate in the assessment of patients and decision-making process, with providers and case managers.
Follow up with patients to ensure their needs are met and the services delivered.
Coordinate the delivery of services to clients and their families.
Collaboration with primary care and specialists, ensuring comprehensive care for patients.
Facilitate medical records requests, authorization verification, and clinical staff communication.
Assist patients and answer questions about policies, benefits, and care coordination.
Team-Based-Care
Our Team-Based-Care efficiently address various patient concerns, improving patient access, including:
Focused Care Clinic Access
Referral Authorizations
Chronic Medication Refills
Medical Records Requests
Secure messaging
Telehealth services
Alternative visits
Afterhours audio visits
Discharge orders review
Lab orders placement
Pre-op orders placement
Billing and Payment questions
Care Plan implementation
Care coordination with specialists.
DME Supplies and Equipment orders
Leadership and cultural sensitivity
Behavioral health in primary care
Social Health Needs assistance.
Focused Care Clinic
Our Focused Care Clinic (VFC Clinic), addresses various patient concerns using Team-Based-Care and Case Management.
Effective communication between the healthcare team members and the patient is essential for mutual understanding and aligning perspectives, to ensure timely access to appropriate care.
CONVENIENT CARE
Non-urgent problems, questions or concerns.
addressed within 48 hours.
CHRONIC PROBLEMS CARE
Questions related to chronic illnesses.
addressed within 48 hours.
URGENT NEEDS CARE
Questions related to acute problems.
addressed within 8 hours.
The doctor determines how urgent a medical issue is by looking at clinical factors, using medical knowledge, and evaluating professionally, as needed. This helps prioritize clinical diagnoses.
The patient’s perception of urgent care may be influenced by symptoms, discomfort, or other concerns, but will depend on the doctor’s decision to determine the urgency level.