Care coordination is a function that supports information-sharing across providers, patients, types and levels of service, sites and time frames. The goal of coordination is to ensure that patients’ needs and preferences are achieved and that care is efficient and of high quality. Care coordination is most needed by persons who have multiple needs that cannot be met by a single clinician or by a single clinical organization, and which are ongoing, with their mix and intensity subject to change over time. – NCQA
SJBH Care Coordination Services Goal
To provide access, guidance and advocacy to those who face barriers to health care and resources, and to support a community-wide approach to reducing those barriers through systems-level work.
The Medical Home Model
Our Care Coordination efforts follow the Medical Home model, where we strive to help our community provide patient-centered medical care that is: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.
Call us at (970)247-5702 to learn more.
SJBH Care Coordination Services Guide
Care Coordination
Nurse Navigators – for everyone
Our Nurse Navigators provide free care coordination to individuals and families (La Plata or Archuleta County resident, or your provider is based here) who have poorly controlled health conditions and/or barriers or difficulties in accessing health care.
- Assess for unmet needs (medical, social, financial, behavioral and educational)
- Identify individual and family strengths
- Develop a goal oriented plan of care with clients, families and providers
- Educate towards greater self-management of chronic diseases
- Help Client achieve healthier outcomes
HCP Team – for children and youth with special needs
Our HCP team (HCP Nurse and Family Focus Clinic Coordinator) provides free services for Children and Youth with Special Health Care Needs (CYSHCN) (those who have, or are at increased risk for having, a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children [and youth] generally) and their families who live in La Plata and Archuleta Counties.
- Intake interview identifies strengths, concerns, culture, and values
- Assessment considers the special health care needs in more detail
- Action plan identifies goals, next steps, responsible persons, target dates
- Review of action plan progress
- Case Closure is decided by child/family and Nurse when finished
Parents Plus Nurse – for families with dependent children
Our Parents Plus Nurse assists La Plata County residents with parenting, health needs, access to health services, and preventive care. Parents Plus is a nurse case management program which utilizes nursing assessment skills and support in the home or office settings.
Parents Plus Project is part of an inter-disciplinary team led by Department of Human Services; to apply for the TANF program, go to the DHS office at 2424 Main Ave, Durango, CO or call (970) 382-6121.
Family Health Coordinator – for families, pregnant women and children
Our Family Health Coordinator helps Medicaid and CHP+ (Child Health Plan Plus) eligible residents of San Juan, La Plata, Montezuma, Cortez, and Archuleta Counties navigate the Medicaid system as well as community resources.
Through Medicaid’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Outreach, they connect families with resources to obtain treatment for medical, dental, vision, mental health, and developmental problems such as well-child visits, diagnosis and treatment services.
Our Family Health Coordinator can assist with applications, access to care, education, referrals, and navigation of services.
Insurance Enrollment
C4HCO Health Coverage Guides – CO Health Insurance Marketplace for everyone
Our Health Coverage Guides give free assistance to La Plata and Archuleta County residents concerning the Colorado Health Insurance Marketplace in response the Affordable Care Act requirement for insurance coverage.
They can assist over the phone or one on one with basic questions or in filling out the online application. If you qualify for Medicaid or CHP+ we can assist you with the online PEAK application as well. They can also assist with questions regarding federal tax credits.
Family Health Coordinator – Medicaid & CHP+ enrollment for women & children
Our Family Health Coordinator can assist women and children residents of San Juan, La Plata, Montezuma, Cortez, and Archuleta Counties with enrolling in Medicaid and CHP+ (Child Health Plan Plus).
CHP+ offers full health care coverage for uninsured Colorado children and youth (up to 18th birthday) and pregnant women 19 years of age and older. The CHP+ plan includes check-ups and shots, other doctor visits, hospitalization and hospital services, prescribed medications, and mental health services.
PE Site Worker – Medicaid & CHP+ for pregnant women
Our PE site worker (Archuleta County) can help pregnant women age 19 and older and their children with applying for immediate temporary medical coverage (Medicaid and CHP+) for outpatient services during pregnancy.
Specialty Clinics
HCP Team – for children and youth with special needs
Our HCP team (HCP Nurse and Family Focus Clinic Coordinator) provides free services for Children and Youth with Special Health Care Needs (CYSHCN) (those who have, or are at increased risk for having, a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children [and youth] generally) and their families who live in La Plata and Archuleta Counties.
Specialty clinics include Pediatric Neurology and Rehabilitation. Our staff can provide referrals, triage and scheduling for new clinic visits and follow up appointments with visiting Doctors from Children’s Medical Center in Denver. They can also assist in coordinating required records from other providers.
There is a sliding fee scale for clinic fees. Medicaid clients have no fee. For questions talk with our staff.
Sliding scale fees:
- No charge for families at or below 100% FPL
- $5 fee per visit for a rating of 101 – 133% FPL
- $10 fee per visit for a rating of 134 to 185% FPL
- $30 fee per visit for a rating of 186 to 211% FPL
- $50 fee per visit for a rating of 212 to 399% FPL
- $75 fee per visit for a rating of 400 to 450% FPL
- $100 fee per visit for a rating of 450% FPL and greater
Call us at (970)247-5702 to learn more.