Social Care Coordination
Social care coordination, as provided by HL4ME CCH, is designed to integrate a person's health-related social needs (HRSN) with their clinical treatment activities. This service connects individuals to community-based organization (CBO) resources to ensure that both they and their caregivers can thrive in the community. HL4ME identifies and coordinates a person's HRSN through a network of CBO partners, aiming to optimize quality of care, improve outcomes, lower costs, and enhance patient satisfaction. The service offers both short- and long-term social care coordination, focusing particularly on food security and nutritional health.
The approach to social care coordination or complex case management involves a systematic process to manage the healthcare and social needs of individuals with complex health conditions. These conditions often include multiple chronic illnesses, disabilities, or significant social challenges that require comprehensive and integrated care. The primary goal is to improve the quality of life for these individuals by ensuring they receive appropriate, timely, and effective care across various services and settings. This involves a thorough assessment and planning, integration of services, effective communication among stakeholders, and continuous monitoring and evaluation.
Key components of this approach include comprehensive assessments, personalized care planning, service delivery, and resource allocation. It also emphasizes ongoing monitoring and necessary adjustments to care plans, patient advocacy, and support services. The benefits of social care coordination and complex case management are significant, including improved health outcomes, enhanced quality of life, reduced hospital admissions, and greater cost-effectiveness. By addressing both medical and social needs, this approach ensures that individuals receive holistic and coordinated care, leading to better overall health and wellbeing.
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