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