SCCP is uniquely positioned to provide comprehensive, person-centered, care coordination services for high risk and high cost populations. Our integrated ecological model of Care Coordination aims at addressing the inter-relational aspects of physical, psychological, and social determinants of health status, through providing a comprehensive array of coordinated, timely, and accessible services that are culturally competent. These services are provided by Clinical Care Managers (RNs, LCSWs) with support from Navigators (CNAs, CMAs).
Our Care Coordination activities include:
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- Health Risk Assessments
- Completing Care Plans with Input from New Members
- Conducting Member Health Education/Health Literacy Activities
- Monitoring and Tracking of Treatment Adherence
- Discharge Planning and Transition of Care Support
- Medication Management
- Utilization Management
- Promoting Wellness Programs and Services
- Interdisciplinary Care Team Huddles
- Appropriate Reporting