Care Coordination in Primary Care
The goal of care coordination is to improve health outcomes for patients. Saint Luke’s care coordination team works collaboratively with the patient and the care team, including nurses, providers, and specialists.
The Saint Luke’s care coordination team includes:
- Care coordinator: A registered nurse who assists with disease management, disease education, medication education, facilitates communication, and advocates on behalf of the patient and family.
- Social service coordinator: A licensed social worker who helps the patient and/or family meet basic social needs, provides support, and assists with long term planning.
- Outreach specialist: A licensed practical nurse or certified medical assistant who assists with hospital transitions, scheduling appointments, identifying needs, and ensuring patient has and knows how to take medications as prescribed.
- Community health worker: A team member who can meet the patient at home, if needed, to help secure additional assistance through community resources.
Patients will interact with these various team members as needed.
What to expect
Visits with the care coordination team can be done in person, by video, or by phone. Be prepared to discuss health goals and any barriers to those goals. The care coordinator works with the patient and family to develop a plan to achieve health goals and navigate barriers that may affect the health care plan. After a visit, the care coordinator will update the patient’s provider.
Long-term care coordination programs
Based on an assessment of the patient’s needs, a determination will be made if the patient would benefit from long-term care coordination, such as:
- Longitudinal Care Management: A nurse care coordinator assists with health care goals, disease education, medication education, and navigating the complex health care system.
- Social Care Management: A social worker supports patient needs outside of the health system and engages with external partners to overcome individual patient barriers in the long term.
Contact us
Contact your Saint Luke’s Primary Care office for more information.