What is Care Coordination?
Care Coordination is making sure your care is the best it can be. Your Care Coordinator will bring all your providers together to make sure they are keeping your goals for health first. You will meet with your Care Coordinator and create a plan that lists all your needs. You will choose goals that are important to you for better health. This is called your Person-Centered Service Plan (PCSP).
What can my Care Coordinator do?
Your Care Coordinator is here to help you.
They can:
- Help you find a doctor
- Help you make appointments
- Find resources like food and transportation
How can I reach my Care Coordinator?
You can reach your CC (Care Coordinator) by phone or email.
1-866-261-1286
[email protected]
Care Coordination Services
Care Coordination will help members with their healthcare needs by making sure everyone works together. CC will also ensure compliance with the PCSP. Care Coordination will help with any resources needed or barriers to accessing treatment.
Your Care Coordinator Can:
- Teach you more about your health needs
- Find services to help with needs in your day to day life including access to healthy food and exercise
- Work with providers to coordinate care
- Make a plan of care that has all your services and goals listed (Person Centered Service Plan)
- Help you find supports in your family and community
- Monitor providers to ensure that services are provided in a safe and helpful manner
- Ensure you regularly follow up for prevention, wellness, and sick visits
- Make sure you have active coverage and assist with paperwork for renewal
- Follow up with you within 7 days of an ER, Urgent Care, or Hospital Admission
- Help with discharge planning, prescription assistance, follow-up appointment with PCP and Specialty Providers
- Help with paperwork
- Provide guidance and support
- Ensure you have an assigned PCP
Person Centered Service Plan
The Person-Centered Service Plan, or PCSP, is your plan of care. Your Care Coordinator will work with you to list all your providers. Your Care Coordinator will gather all care plans from your providers. The goal is to prevent duplication of services. Your CC will coordinate care between all your providers. Another important part of the PCSP is identifying your needs. Your care coordinator will help find resources to meet those needs.
You are the most important part of the PCSP process. You will identify goals that are important to you. Your Care Coordinator will help you achieve those goals by providing health education, coaching and support.
Your PCSP will include the following types of treatment or service plans:
- Behavioral Health Treatment Plan
- Waiver client Person Centered Service Plan
- Primary Care Physician Care Plan
- Individualized Education Program
- Individual Treatment Plans for developmental clients in day habilitation programs
- Nutrition plan
- Housing plan
- Any existing work plan
- Justice system-related plan
- Child welfare plan
- Medication Management plan
Your PCSP will list additional services that are available to you. This may include:
- Adult rehabilitative day service
- Behavioral assistance
- Child and youth support services
- Family support partners
- Medication counseling by a registered nurse
- Mobile crisis intervention
- Partial hospitalization
- Peer support
- Recovery support partners (for substance abuse)
- Residential community reintegration program
- Respite, emergency and planned
- Supportive employment
- Supportive housing
- Supportive life skills development
- Therapeutic communities
- Therapeutic host homes
- Substance abuse detox (observational)
Our Clinical Model
Your care coordination staff has been assigned to you based on your specific needs. Each of Empower’s specialty populations have their own clinical teams that offer unique programs and services. Click on each specialty population below for more information.
- Complex Care
- Transition of Care
- Post Adoption
- Foster Care
- Adult Behavioral Health
- Pediatric Behavioral Health
- Developmental Disability/Intellectual Disability
Your First Visit
At the first visit, you can expect the following from your Care Coordinator:
- Introduction and Overview of Care Coordination
- Contact Information for the Care Coordinator and Toll-Free Number
- Completion of the Healthcare Questionnaire
- Discussion of Goals for Care Coordination
- Obtain Release of Information for Providers and Support System
- Healthcare Questionnaire which covers the following:
- Current Health Status
- PCP Information
- Diagnosis
- Medications
- Providers
- Resources/Barriers to Care
- Financial
- Legal
- Transportation
- Cultural/Linguistic
- Housing
- Disabilities
- Support System