Coordinated Care

In Population Health, the primary care physician (PCP) quarterbacks your care and will be your primary contact as they coordinate health services with other members of your care team. The PCP will not restrict access to specialists but will work closely and effectively with them to ensure you receive timely, evidence-based medical care. In addition to the quality services you already receive from ARC, your Population Health team will take special care to explain medications and treatments, provide detailed care plans for your conditions, regularly offer you lifesaving screenings and immunizations, and help you achieve your personal health goals through education and support.

Coordinated care improves overall health quality and efficiency by emphasizing preventive medicine and improving the patient’s experience of the health care system. The Population Health coordinated care services include:

• Chronic care nurse navigators for patients with high-risk and/or complex chronic medical issues who need extra nursing support.
• Hospital/ER transitions services to coordinate inpatient and emergency care and help you reconnect with your PCP after your hospital or ER visit.

Chronic care nurse navigators

Chronic Care Nurse Navigators work with patients with diabetes, congestive heart failure, obstructive pulmonary disease, and other lifelong health challenges. If you are a patient with chronic and/or complex health issues and are recommended by your PCP, you will receive a letter from one of our nurses who becomes your dedicated Nurse Navigator. Once notified, your Nurse Navigator will work together with your PCP and your current care team. Nurse Navigators assist with setting realistic diet and exercise goals, help schedule regular follow-up appointments, offer preventative care opportunities, find community health resources, and support you and your family during stressful health events. These specially trained Registered Nurses (RNs) can help explain complex diagnoses, answer your questions, and help create a care plan which matches your unique needs and values

Hospital/ER - transitions service

Our Hospital/ER Transitions Nurse Navigators assist when patients are admitted/discharged from an acute care facility with the goal of reducing the possibility of a return trip to the hospital. Our Registered Nurses (RNs) may visit while you are in the hospital or call to see how you are doing after discharge. They can help you understand your discharge instructions, figure out medication changes, and let you know when you should call your doctor during this critical transition. These Navigators will help you schedule follow-up appointments with your PCP and/or specialist, as well as address any concerns you have after your visit to the hospital.