Care Coordinators

Care Coordinators

A Care Coordinator collaborates closely with patients and the clinical care team to support individualized care plans and address overall healthcare needs. The Care Coordination team partners with providers and clinical staff to promote the delivery of high-quality, value-based care for Northshore patients. Care Coordinators are available to provide education, coordinate services, and assist with navigating healthcare needs across the Pediatrics, Family Practice, Women’s Health, and Behavioral Health departments. 

Pediatric Care Coordinators

Pediatric Care Coordinators provide one on one office visits with families for education, support, referral assistance and assist with individual needs that patients and families may have. They meet with patients from Newborn to age 2 at all milestone visits. The Pediatric Care Coordinator collaborates with provider and clinical staff to provide a seamless care team experience.

  • Newborn visits 
  • Milestone visits up to 2 years old: Education and support of developmental stages 
  • Car seat installs and checks 
  • Referral assistance 
  • Assist with scheduling well child checks. Support compliance with vaccine guidelines. 
  • Safe Sleep: Education and Pack N Play referral program 
  • Coordinates outside services to specialists, therapies, medical equipment, diaper pantries 
  • Nutritional needs: lactation referrals, WIC referrals, formula samples 
  • Big Brother. Big Sister sibling classes 
  • Co-facilitate Centering Parenting group visits 
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fam practice

Family Practice Care Coordinators

Family Practice Care Coordinators support and coordinate the overall health of patients, focusing on chronic illnesses and preventative measures in collaboration with providers. They offer in office education and also present class-based education on Diabetes topics. The Family Practice Care Coordinators are also available to coordinate care. resources, and services patients need.

  • Chronic condition education through lifestyle changes and goal setting 
  • Coordinate referrals to specialists  
  • Coordinate medical equipment needed 
  • Contraception education 
  • Nutritional needs: education, food pantries, other community programs 
  • Address barriers to care: community resources, transportation, housing 
  • Healthy living education: Smoking cessation, stress management, physical activity, preventative screenings 
  • Coordinate follow up after ER visit or hospitalization. 

Women's Health Care Coordinators

Women’s Health Care Coordinators work with providers to coordinate maternal and women’s health to achieve the best possible health outcomes for mothers and newborns. They help coordinate maternity services, prenatal education and gynecological needs of patients. The Women’s Health Care Coordinators work closely with Pediatric Care Coordination team to ensure a proper transition of care for mother and baby.

  • Pregnancy testing and verification 
  • Initial OB visits 
  • Administer NST as ordered by provider 
  • Prenatal education by trimester 
  • Contraception education 
  • Car seat checks and installs 
  • Co-facilitate Centering Pregnancy group visits 
  • Coordinate referrals to specialists 
  • Coordinate maternity belts, breast pumps and other medical equipment 
  • Post partum follow up visit check in 
  • Nutritional needs: education, food pantries, other community programs 
  • Address barriers to care: community resources, transportation, housing 
  • Assist with resources for breast screenings and cervical screenings for uninsured patients. 
  • Partner with Nurse Family Partnership to coordinate home services as needed.
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mental health

Behavioral Health Care Coordinators

A Behavioral health Care Coordinator is available to support and coordinate both the mental and physical health of patients. They work in collaboration with the medical provider and mental health providers to ensure best possible mind and body wellness for patients.

  • Schedules appointments for Behavioral Health, SUD and Psychiatric providers. 
  • Coordinate follow up care after ER visit, hospitalization or stay at inpatient facility. 
  • Address barriers to care: community resources, transportation, housing 
  • Coordinates and helps locate access to individual and family support groups 
  • Coordinates referrals to specialists 
  • Nutritional needs: education, food pantries, other community programs 
  • Healthy living education: Smoking cessation, stress management, physical activity, preventative screenings 
  • Household needs: housing resources, Homeless / family violence shelters, clothing resourcesÂ