Outpatient care management

The outpatient care management team is a health navigation team that focuses on providing one-on-one support for improving health. Specifically, the health navigation team works with clients who frequent the hospital and ER often, live with a chronic disease and have limited social support. It understands and tailors its services to various cultural backgrounds and advocates for improvement of its clients’ healthcare experiences and outcomes.

If you are an eligible community member, the team will work with you to help address your unique barriers to improving your health. The team of nurses, community health workers and public health professionals focuses on:

• Providing disease management support and counseling.
• Answering questions about medications.
• Providing post-discharge home visits to review discharge instructions.
• Developing care plans with primary care providers.
• Accompanying clients to doctor’s appointments to address medical literacy issues and to provide advocacy.
• Conduct regular home visits.
• Providing social support.
• Helping clients navigate and connect with available social and health resources.
• Offering one-on-one health education and individualized goal setting.
• Providing basic health screenings and checks by an RN or CNA.