Care coordination is when someone helps you pull together the pieces of healthcare. This puzzle fits your unique needs.  The people who provide care coordination are called Community Health Workers.  They act as your personal guide in a number of ways. First, they help you find what you need in the healthcare system.  They match you to providers and make sure your needs and preferences are met. Second, they coach you to create and follow through on your health goals. Finally, they work to lower healthcare costs for people on Medicaid and Medicare.

Care coordination services

  • Assistance with community resources. This can include: housing applications, food security and food assistance applications, SSI/SSDI application assistance, understanding medical coverage and assistance with advocacy.
  • Coordination of medical care among specialists and the patient’s primary clinic, or medical home.
  • Assistance with Medicaid Non-Emergency Transportation set up and scheduling.
  • Education of resources and education around a patient’s specific illness or diagnosis.
  • Help for patients with complex medical needs, such as dual diagnosis; or transitions to skilled nursing, group homes or other medical/behavioral facilities.

Meet with a Community Health Worker

People are eligible to meet with a CHW if they are patients at one of Axis Health System’s integrated clinics, or if they are willing to become a patient. If you are interested in CHW services, speak to your clinic provider, or schedule an appointment at the clinic’s front desk.