Care Coordination Program

Many patients and families need support beyond the walls of a doctor’s office or hospital. The Atlantic Health System Care Coordination program is a complimentary service to help patients stay healthy and thrive in their community after receiving medical care. Our team works with staff in our hospitals and physician practices to identify patients who may benefit from medical, social, and community support. Our goal is to improve overall health in our communities and ensure that every patient has access to the right resources, at the right time, in the right setting.

How We Can Help

• Educate patients on how to recognize symptoms and access health services before issues become an emergency
• Review drug prescriptions and work with pharmacists to provide safe and affordable medications
• Monitor patient progress and health through remote patient monitoring
• Help patients and caregivers access mental health care and social support
• Connect patients with community and financial resources to improve their well-being and achieve their goals

Patient Care Team

Transition of care coordinator nurses

A transition of care coordinator nurse works with patients on a plan to support their health after they leave the hospital. This coordinator guides the patient and their loved ones through the transition to home or another care facility.

Post-acute care coordinator nurse

If a patient needs medical care at a skilled nursing or rehabilitation facility before going home, a post-acute care coordinator nurse joins the patient care team. These nurses make bedside visits and assist post-acute care facilities in meeting the patient’s social and medical needs. Atlantic Health System’s High Performing Network can help patients find the best fit for their post-acute care needs. 

Ambulatory care coordinator nurse 

When a patient returns home, an ambulatory care coordinator nurse works with patients to manage their doctor’s appointments, medications, and treatment plan. Coordinators teach patients how to monitor their symptoms and support their health from home.

Social workers

Social workers engage patients in improving their physical and behavioral health by connecting them to community resources. Social workers help patients address substance misuse, mental health issues, and social determinants of health needs such as unstable food, living, or financial situations.

Community health workers

Community workers visit patients in their community and support them in applying for social service and financial programs. They build relationships with patients to help them reach their health and wellbeing goals.

Addressing Social Determinants of Health

Social determinants of health (SDOH) are life conditions and experiences that have a direct effect on your physical and mental health. SDOH factors include economic stability, access to food, transportation, stable housing, and education.

Many people struggle to access health services and live a healthy lifestyle because they must focus on tasks like caring for a loved one, finding a job, or finding stable housing. Addressing SDOH needs by linking patients with behavioral health support and community resources can improve the overall health of individuals, families, and populations.

Through care coordination, patients can access supportive resources to address medical and social barriers to care. If you feel that you would benefit from care coordination, talk to your care provider or call the care coordination team.