Hospital-based Patient Care Coordinator

• Assigned while patient is in-house by meeting criteria
• Works with patient and family during inpatient stay
• Stays with them for 30 days post-discharge
• High touch, face-to-face Whole person management
• Funded by hospital
• Based on comprehensive plan of care Behavior Modification

Care Manager Assistants 

• Verify guardianship with court
• Obtain PCP
• Transmit documentation
• Call/fax provider offices
• Make phone calls, fax, scan, etc.

Community-based Care Coordinators

• Follow-up with post-discharge caregivers for patient status
• Very specific/focused type of patient
• High utilization / High-risk patients
• Follows patient into the community
• Very involved with the patient and their care
• Involvement in more than “healthcare” concerns to keep patient out of hospital
• Monitoring of in-home electronic health monitoring