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UR Medicine / For Referring Physicians / Comprehensive Care Coordination Center
 

Comprehensive Care Coordination Center (CCCC)

Purpose

To have one place for providers or designees to have access to resources that will aid in care coordination for their patients in the URMC system.

What Does the Center Do and How?

The service aims to coordinate and optimize the social, medical, and psychosocial health of the patients in the URMC system through a collaborative team approach.

The CCCC consists of a panel of nurse liaisons experienced with the system's resources, who can assist providers and care managers with getting their patients connected with services or resources needed to help them manage their care more effectively.

Providers or designees can have access to the CCCC from many different points of care including:

  • Episodic Care Management
    • Hospital Service Line Clinicians
    • Specialty Care Providers
    • ED/Urgent Care/Inpatient Care Coordinators or Social Workers
    • Nursing Home or Home Care Case Managers
  • Population Care Management
    • Primary Care Providers
    • Specialty Care Providers
    • Health Home Case Managers
    • Payor/Plan Management Programs
  • Employee Wellness Program

Specific Resource Examples

CCCC patients can receive a variety or services. Services vary, depending on patients' medical and psychosocial complexities. These services can include:

  • Referral to Health Homes (Medicaid only)
  • Home Care
  • Complex Wound Management
  • Community-based Social Work Support
  • Health Outreach Workers
  • Transportation
  • Financial Counseling
  • Access to Community Services
  • Behavioral Health consults
  • Pharmacy Management
  • Palliative Care/Hospice consults
  • Telehealth
  • Health Coaching
  • Chronic Disease Management Programs
    • Heart Failure
    • Diabetes
    • Hospice/Palliative Care
    • Others
  • Wellness Management

Eligibility Criteria

All patients are eligible.