Care Coordination Services Provided

Preadmission/Admission Assessment
(prospective and referral-based)

  • Risk Assessment
    • clinical appropriateness
    • projected LOS
    • financial clearance/risk for COB/free care eligibility
    • psychosocial risk (abuse, guardianship, advance directives)
    • projected discharge needs

Oversight and Facilitation of Plan of Care

  • communications, team and patient/family, payer and community
  • clinical appropriateness, authorizations and approvals, payers and PCP’s
  • facilitating plan of care

Patient Education and Staff Support

  • continuity and consistency of plan of care, and communications amongst providers and patient/family, payer and community
  • patient education about financial implications, levels of care and post-acute providers of care required to meet ongoing care needs after discharge


  • Communications with patient/family, team, community, payer/PCP/outpatient care coordinator


  • Patient Assessment
  • Progress Notes
  • Clinical Pathways
  • Referrals

Utilization Management

  • MCAP (Managed Care Appropriateness Protocol)
  • Clinical denial management
  • Utilization Review

Post-acute Calls to Patients

Care Improvement Initiatives

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