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Care Coordination

The Care Coordination Department exists to provide continuity of care among providers of services; to educate, advocate for, and empower patients and families to attain self-sufficiency; to link families with community resources; and assist patients and families in navigating the various systems in order to attain the highest quality of care, while maintaining confidentiality and privacy.

We are committed to providing need-driven services in a timely individualized, patient/family-centered and culturally sensitive manner.

Our services include the following:

  • Assistance with Enrolling in the Health Insurance Marketplace

  • Insurance referrals for assistance with subspecialists

  • Disease education and case management

  • Help with basic needs

  • General social services (assistance with community programs)

  • Assistance with insurance and Social Security disability applications and appeals

  • Job training referrals

  • Transportation

  • Spanish interpreter/Translator services

 
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More Information About the Responsibilities of our Care Coordination Staff

Insurance Referral Specialists: The Insurance Referral Specialists coordinate subspecialists’ referrals. They schedule and coordinate appointments with the appropriate subspecialists providing them with demographics, insurance, diagnosis and medical/diagnostic information, as well as contact patients and/or caregivers with appointment information. Specific services include appointment scheduling and follow up with subspecialists (cardiology, x-rays, ultrasounds, urology, etc.) and assistance with insurance pre-authorization and pre-certification (commercial insurance or TennCare).

Medical & Disease Case Managers: The Medical & Disease Case Managers facilitate family access to medical home providers, staff and other resources. They serve as contacts, advocates and as a resource for families, the community, and other social or medical agencies and provide the following:

  • Disease education

  • Assistance with home health care

  • School services (attend team meetings, IEP, IFSP, GEIT, etc.)

  • Durable medical goods (G-tubes, diapers, etc.)

  • Durable medical equipment (wheelchairs, medical beds, etc.)

  • Written correspondence

Social Service Case Managers: Social Service Case Managers assist individuals and families in navigating social service systems to attain the highest quality of life.

  • Link families with basic needs, community services and resources (food, clothing, food stamps, utilities, domestic violence, etc.)

  • Insurance (assist with application and appeal processes)

  • School and other agency meetings (IEP, IFSP, GEIT)

  • Social Security disability application assistance

  • Job training referrals

  • Budgeting

  • Transportation

  • Written correspondence

Outreach and Enrollment Counselor (Certified Application Counselor): The Outreach and Enrollment Counselor is responsible for conducting public education activities at Mercy Community Healthcare and in the communities of Williamson, Maury, Marshall and Hickman Counties to raise awareness about health insurance coverage options under Medicaid (TennCare), CHIP and the Affordable Care Act Marketplace, as well as enrolling consumers in medical insurance plans.

This individual also connects families with community services and resources (food, clothing, food stamps, utilities, etc.), and assists with insurance applications as well as appeal processes.

Spanish Interpreter: Our Spanish Interpreter provides timely, individualized, patient-centered and culturally sensitive Spanish interpreting and translation services.

Legal Aid Clinics: Through Mercy’s Medical Legal Partnership with the Legal Aid Society of Middle Tennessee and the Cumberlands, and in collaboration with St. Andrew Lutheran Church in Franklin, Mercy provides legal advice clinics (criminal issues excluded) for communities in Williamson and surrounding counties on the first Thursday of each month, starting at 4:30 p.m.

Chronic Care Management Program: Mercy’s Chronic Care Management Model is an organizational approach to caring for people with chronic diseases in a primary care setting. Objectives of this program include, but are not limited to:

  • Improve/maintain functional status

  • Improve/maintain quality of life

  • Increase patient satisfaction

  • Improve compliance with care plan

  • Improve patient safety

  • To the extent possible, increase patient self-direction (autonomy)

  • Reduce/prevent urgent care visits, ER visits and hospitalizations

  • Overall saved healthcare cost for the patient


 

Care Coordination is a unique and important service we provide at Mercy Community Healthcare. Hear from Behavioral Health Counselor Abbie Nelson about how the integrated services Mercy provides, including those provided by our Care Coordination Department, allow her to better do her job.