Care Coordination: A Community Response Model

About the Program

Category: Health (Best in Category)

Year: 2014

In April of 2012, Summit County Public Health’s Care Coordination Program entitled Care Coordination: A Community Response Model was created to assure access to all services addressing health disparities that exist as a result of resources and access, particularly for vulnerable populations. Trained outreach specialists and public health nurses, work closely with residents of Summit County to assure access to any necessary services including health care access, housing, transportation, medications, dental/ vision services etc. Through Care Coordination, four independent projects have been developed and successfully implemented to address needs of different vulnerable populations within the community. These programs are Adult Protective Services, Access to Care, Certified Application Counseling, and the Million Hearts Campaign. The concept is as a new need is identified, Care Coordinators can respond quickly to meet that need. 1) The Access to Care (ATC) program is a volunteer network of 300 primary and specialty care physicians that provide care at no cost to participants. Care Coordinators assess eligibility for this program and serve as a patient advocates and link clients to free or reduced cost care. 2) Adult Protective Services (APS) is collaboration with the Summit County Department of Job and Family Services and puts services in place for adults age 60 and older who are at risk for abuse, neglect, self-neglect or exploitation. Care Coordinators, Public Health Nurses, Adult Protective Service workers and Registered Sanitarians address the needs of this population via an interdisciplinary team approach. 3) Certified Application Counseling is a new venture for Care Coordination as it was implemented mid 2013 to address the need for healthcare access recently granted through the Affordable Care Act. Care Coordinators help consumers with eligibility, facilitate enrollment, and provide information in the best interest of the consumer. 4) The Million Hearts Initiative aims to prevent one million heart attacks and strokes by 2017. Care Coordination assists with this effort by working with 12 Family Practice Providers in the County to educate provider staff on resources available through SCPH and the Care Coordination Program, to establish referral protocols for providers to connect patients to SCPH, and to provide additional information and resources that may help providers improve their systems of care for hypertension patients.