Our Care Coordinators assist individuals through transitions such as hospitalization or rehabilitation admissions or perhaps adjusting to assisted living settings. Providing support in obtaining preventative care, medical equipment and supplies and supports for health needs such as: arranging transportation to medical appointments, filling prescriptions and making referrals. Our team's motto is whatever it takes to achieve wellness.

 

We have two Care Coordination Programs?

1. High Utilizers  

The target population of CCT patients are 18 and over, high utilizers of services (typically defined as 3 adult crisis /detox admissions in 180 days) and may also be impacted by high usage in jail, local emergency rooms, and homelessness.

2. Private Care Coordination

Co-located within Emergency Rooms and local hospital systems of care. Typically, these patients have complex medical conditions.  

• Referrals are identified through Gracepoint’s EMR system, Central Florida Behavioral Health Network, or a local hospital.

• These services are intended to be short term to accomplish the patient’s goals. 

• The typical length of service is 60 days, some may be a short as 30 days up to 4-5 months.

• Services:

  • Case Management

  • Transportation

  • Assistance with housing, linkage to primary care and behavioral health

  • Assistance with disability income and health insurance applications

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