CARE COORDINATION SERVICES
Our interdisciplinary care teams support people by addressing health related social needs such as unstable housing or food insecurity, arranging for services in the home (e.g., nursing or homemaking), connecting individuals with addiction services, identifying medical or behavioral health providers, scheduling health appointments and setting up transportation to those appointments, and health and wellness coaching.
Our interdisciplinary teams include nurses, licensed behavioral health clinicians, community health workers, and recovery support navigators. Community-based teams provide support within the Boston area, Somerville/Cambridge, Lawrence/Haverhill area, Greater Lowell, Plymouth area, and on Cape Cod.
WE OFFER SEVERAL TYPES OF CARE COORDINATION PROGRAMS:
- Behavioral Health Community Partner Program (BHCP)
- Long Term Services and Supports Community Partner Program (LTSSCP)
- One Care Health Home Program
- Community Support Program
CARE COORDINATION SERVICES INCLUDE:
- Connection to social service supports for which a member is eligible including food stamps, fuel assistance, and delivered meals
- Communication and coordination with medical, mental health, and substance use providers
- Access to primary, specialty medical, and behavioral health care
- Assistance with navigating Department of Mental Health (DMH) services
- Arranging for in-home services when needed including nursing or homemaking
- Health and wellness coaching, beginning with a comprehensive assessment of overall needs
- Help scheduling health appointments including coordinating transportation
- Support after coming home from a stay in the hospital or a rehab facility
- Connections to local community groups such as cultural centers, religious groups, or other social activities
- Connection to recovery supports
- Help with healthy living activities such as smoking cessation, eating well, exercising, or sleeping better
- Help with learning stress management tools such as walking, stretching, talking, or joining a support group
- Understanding enrollment paperwork needs in order to keep MassHealth services.