Care Coordination

Telemedicine, Home Visits, & Transportation
in Mill Creek and Elkins, WV

Valley Health Care offers comprehensive care coordination to help ensure that our patients in Elkins, Mill Creek, and surrounding areas in West Virginia, are able to access the essential health care necessary to live their best possible lives. Care coordinators bring equal access to patients by providing innovative solutions to common problems that many rural residents face when in need of health care services. We work hard to break down these barriers by offering access to transportation and telemedicine, as well as home visits and many other services.

Access to Vital Services Grows Stronger Communities

Care coordinators work directly with patients in their homes to identify needs and help meet goals for improved health, self management, and better comprehensive health care. Appropriate access to vital health services enables our patients to feel better physically and mentally. It also decreases the need for crisis services. By accessing available resources, our residents are able to improve their circumstances and our communities are growing stronger. The essential services provided by our Care Coordinators span an extensive range. All community members benefit from the duties and responsibilities that our Care Coordinators provide to help improve the overall well-being of our clients.

Care Coordinators Link Patients With Community Resources

Care Coordinators form a vital link to connect our patients with the numerous community resources available. We research and identify which resources and support services will best meet the basic, personalized needs of each individual in conjunction with assessing unmet patient needs. In some cases, the needs of the entire family are considered. Care Coordinators identify individuals with special healthcare needs, as well as families who are likely to benefit from our services. We then initiate contact and regularly re-evaluate the level of care coordination required.

Care Coordinators work hard to decrease frustration and worry via effective communication. We help ensure that appropriate housing, transportation, timely access to care, in-home services, and assistance with other basic needs are met in order to facilitate the well-being of each patient and his or her family. By meeting with our patients on a regular basis to provide education, assistance, referrals (when necessary), and explaining our role and how we can help, we strive to promote confidence and enhanced self-management for our patients.

Nursing Home and Assisted Living Oversight

The Care Coordinators of VHC provide valuable oversight for patients residing in assisted living facilities and nursing homes. We serve as the main point of contact to coordinate with and schedule visits with other care providers. In addition, our team of care coordinators provide oversight of the programs that have been developed to help facilitate cohesive relationships.

Care Coordination for Chronic Disease and Substance Abuse Management

Our Care Coordinators serve many types of at-risk and in-need populations, including the chronically and terminally ill, patients with substance abuse issues, and other underserved populations. By using patient lists, we are able to manage the patient population, coordinate with each individual’s family and care team, help ensure compliance, and minimize any gaps in healthcare coverage necessary to manage diseases and addiction-related matters.

We provide targeted services for our patients with substance abuse issues to help these patients best manage their recovery and stay on the path to lasting success. Our Care Coordinators perform drug assessments (including the Clinical Opiate Withdrawal Scale Assessment), and manage the Vivitrol program, including follow-ups. We monitor all local, state, and federal prescription regulations, and ensure compliance with internal controlled substance policies. We also follow-up with patients via urine, drug and pregnancy screenings, as necessary.

Comprehensive Care Team Coordination & Appointment No Show Management

Each patient’s Care Coordinator is the main point of contact for all community-based services. Comprehensive coordination helps ensure that the optimal benefits are obtained for each patient. We conduct patient care team meetings to discuss any ongoing needs, progress, and changes that should be made relevant, as well as information, updates, and keep an ongoing record and signature sheet. Patients with a history of no-shows for appointments are contacted for follow-up and to provide guidance and direction. Our team also works to decrease the frequency of emergency department visits and instead guides patients toward the effective, quality care with continuity that is best obtained via a family doctor. When appropriate, patients are provided with educational information and referrals to the appropriate services available from VHC.

Ongoing Support by Qualified Care Coordinators

The services of Care Coordinators do not end following patient enrollment. We provide ongoing support for all major healthcare-related life spheres. We evaluate quality of care, patient outcomes, and achievement of goals. We strive to increase the utilization of preventive care, continually evaluate patient needs, and follow up on all relevant sources of patient data. We access and manage data from the Lightbeam database, manage the ACO-identified patient population, help facilitate all aspects of Transitional Care Management (TCM) and Chronic Care Management (CCM), as well as locating all testing that has been completed. Care Coordinators examine patient charts and ensure that the electronic medical record is accurate, in addition to taking any necessary steps to improve quality across the board.

Contact us to learn more about how our Care Coordination Program can help improve the life of you or a loved one, or to schedule an assessment.