Care Coordination

The KCHN Care Coordination Program is part of a team of professionals made up of doctors, nurses, social workers, local agency representatives (from HopeSource, Comprehensive Healthcare, Aging and Long-term Care to name a few) as well as Promotoras de Salud, Community Health Workers, Care Coordinators and Community Paramedics.

Clients are referred to our program by a provider or community member with the consent of the client, or the client can refer themselves. After we receive a referral we contact the client within 5 business days. We screen them for their needs, explain our program, and obtain consent to share their information with our partners so we can best assist them in improving their situation and health.

Next, the Care Coordinator and Community Paramedic contact the client to schedule a home visit. During this home visit the Community Paramedic will assess vital signs, take a medical history, and check the client’s understanding of their medical needs while the Care Coordinator listens. The Care Coordinator will then talk with the client to assist them in making goals based on the needs discussed with the Community Paramedic in the first part of the visit.

All this information is shared with the team so that we can assist the client with bettering their health and safety. We can refer them to services and programs with a warm handoff. Complex clients can remain in our program for further assistance, advocacy, and monitoring.