Adult Health Care Coordination connect our Community Care Coordinators (Community Health Workers) with patients from primary care practices and others who are referred from Medicaid health plans. The Coordinators complete a social and medical access assessment to identify the needs of patients in meeting chronic disease self-management goals as well as finding resources to eliminate barriers to regular and timely medical care. Barriers include unstable housing, transportation for medical and other routine appointments; reviewing medications to ensure clients are following their doctor’s current medication plan. We work closely with doctors, practice managers and clinical care coordinators. Connecting clients to mental health services has become even more important. HCAN maintains an active network and connections with community services to ensure that clients will not experience delays in getting appropriate care.
One of the Adult programs is currently funded by bi3 and works with physicians and their patients who receive primary care at the Faculty Medical Center, Good Samaritan Hospital. A new program, Community Transitions & Re-Entry, connects with women returning from incarceration. HCAN also works with the Ohio Medicaid Plans and currently accepts direct referrals from plan providers in Hamilton County. United Way of Greater Cincinnati is also an investment partner with our adult services.