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Outreach

Community Support Specialists (CSS) are available at all our locations. Community Support Specialists assist patients with locating services within their community that enable them to access healthcare services such as transportation to and from medical appointments, housing assistance and fuel assistance. They can also help with insurance concerns for both Medicare (including help with Part D plans) and Medicaid and can provide limited assistance with the Health Exchange.

The CSS can assist patients with:

  • Medical Assistance application
  • Connections with pharmacy services
  • Connections with energy assistance, cash assistance and food stamp programs
  • Referrals to Community Health Workers

Your Community Support Specialists have also had special training to help you understand how to overcome some of the difficulties in managing chronic   diseases such as Diabetes and High Blood Pressure in your everyday life.

Care Coordination Nurses review trends in care and assist medical providers and patients in navigating the complex system of health care. This includes hospital and ER follow-up as well as ensuring patients with chronic diseases are provided with support to follow their individualized plan of care.

Dental Case Management is essential to track high risk patients to ensure they have timely access to quality dental care. Our Dental Case Manager contacts patients who have been identified as high risk through our school based program, dental and medical programs to identify any barriers that may exist that would prevent the patient from following through with necessary dental care.

Panel Management is a process to review patient rosters from Managed Care Organizations (MCO) who are due for select services such as well visits, cancer screenings and immunizations. Patients are contacted and scheduled for appointments and coordination with the patients’ MCO ensures patients receive care they need to remain healthy.